EXIMIUS
PSYCHIATRY-Case History
0000 National Center for Mental Health, Nueve de Pebrero, Mandaluyong City
Diagnostic Conference, January 14, 2009
General Data
F.E., 30 years old, male, married, Filipino, Roman Catholic,
elementary graduate, tricycle driver and part-time mechanic, born on
June 22, 1978 in Zaragoza, Nueva Ecija, but presently residing at
Morning Breeze, Caloocan City, brought by father and admitted for
the first time last October 11, 2008.
Presenting Complaints:
According to informant: “di natutulog”
“nagwawala”
“naninipa, nanununtok”
“di masyadong nagsasalita”
“may papatay daw sa pamilya nya”
According to patient: (patient is staring blankly)
Duration of illness:
Onset: 8 days PTA (October 8, 2008)
Informants: 1. F.E., 60 years old, male, father, high school
graduate, does not live with the patient
2. C.E., 61 years old, female, mother, high school
graduate, does not live with the patient
3. M.E., 32 years old, female, wife, high school
graduate, lives with the patient
4. M.M., 50 years old, female, mother-in-law, high
school undergraduate, previously lived with the
patient
5. R.V., 50 years old, male, best friend, high
school graduate, does not live with the patient
6. Social case report
7. Patient
Reliability: 70-80%
History of Present Illness:
Patient was doing well as a tricycle driver and part-time
mechanic at Morning Breeze, Caloocan City. He is known in their
place as very quiet and accommodating especially to his friends
when he is requested do something for their vehicles.
Sometime in the 2nd week of September, 2008 (25 days
PTA), upon the recommendation of one of his friends, he was hired
by a certain Resty in Malacanang to troubleshoot the breaks of a
loader. The contract was P8,000 for 4 days. And he brought with
him two other companions, whom he paid for all their expenses.
However, it took them almost 2 weeks to finish the job for there were
other problems in the truck that they fixed. And he was paid P7,000
only with P4,000 given to his companions.
At the end of the month (11 days PTA), he was again hired
by Resty, this time on a dump truck machine. The contract was
P80,000 for a month, as suggested by his friend, Harold, to get even
with Resty, who paid him less in their prior deal. Together with his 4
other companions, they started the job immediately.
However, for the first 2 days of October 2008, he
intentionally got absent from work because he got peeved with
Resty’s frequent comment to a certain Director Torres that he works
slowly. When he got back on the 3rd day (8 days PTA), he was
threatened by Resty that he’ll be thrown to the river. Thereafter, he
became nervous but still continued with his work. When he got
home, he was noted to be in deep thoughts and less energetic. His
wife even nagged him for instead of prioritizing his children, he had
ordered for a P3,500-worthed cock as a gift for Resty. On that same
night, he was observed to be outspoken, repeating over and over
previous events in his life. He kept on brooding why he is treated as
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EDITOR:
2021
such and all he wanted was to be fair with anybody. He was able to
retire but already late.
The following day (7 days PTA), he was still able to go to
work. At home, his wife kept on pressuring him over finances. But
he was unmindful of her and remained looming over the same thing.
This time, he was more outspoken but still relevant.
Six days PTA, he went to visit his best friend at Novaliches,
Quezon City and was noted by the latter that he was not his usual.
He could not keep still inside the house, touching anything inside
and still brooding on Resty’s comment. He also went home very early
at noon time that he seldom used to do. He complained of headache
and nape pain but he refused to go for a consult and went to sleep
instead until the following day.
Five days PTA, upon waking up and finding his motorcycle
wheels have been stolen, he immediately approached their neighbor
and accused him as the culprit. He was pacified by his wife and he
prepared for work. Before he left, he told his wife that he already
lost his love for her. After a few paces, he went back and told her not
to believe what he said and assured her he can control himself.
When he reached Malacanang, he was surprised there
were other workers doing the job, whom Resty hired as
replacements for him. He became irritable and shouted profane
words to the people there. He was sent out by the 2 security guards
there and allegedly, two policemen approached him, punched him in
the stomach and dropped him off to Quiapo, where he was fetched
by his uncle. At home, he remained still in one place, very quiet and
staring blankly. On the same night, he was unable to go to sleep,
oftentimes seen smiling to self, and uttered irrelevantly. He
frequently drank water, switched their lights on and off, and looked
over for their knives (hid by his wife) for there were alleged threats
to him as he was poked by a gun. He was able to sleep at 3 AM. She
immediately sought help from his uncle nearby and his parents in
the province were asked to come over.
Family Medical History:
The patient has heredo-familial history of hypertension and
heart diseases on both sides of his parents. His father has
maintenance drugs for enlargement of the heart. His maternal
grandmother died of complications due to DM. Also, his maternal
aunt had PTB. There is no history of goiter.
He has a deceased paternal uncle who had undocumented
mental illness with symptoms of impaired sleep, wandering around
their place aimlessly and talking to self. No consult was done.
Likewise, his mother was observed to have blank stares,
impaired sleep and smiling and mumbling to self after she had given
birth to her second child. However, no consult was done for she
remained manageable and functional at home, though, relapses
were noted almost every year lasting for 3 months at the most.
There was no history of suicide in the family.
Past Medical History:
The patient had history of childhood disease like chicken
pox, mumps and measles. He has no history of seizure disorder, no
history of head trauma, no history of hospitalization or operations
done. He has no known allergy to drugs and foods.
Personal and Social History:
Prenatal/Perinatal
The patient is the eldest in a brood of 3; a product
of planned and wanted pregnancy by a G1P1 mother
delivered full term through normal spontaneous delivery
assisted by a midwife and traditional birth attendant at
home. No feto-maternal complications were noted. Her
mother had prenatal check-ups at a local Health Center but
had irregular intake of Multivitamins. She had no exposure
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PSYCHIATRY-Case History
0000 National Center for Mental Health, Nueve de Pebrero, Mandaluyong City
Diagnostic Conference, January 14, 2009
to radiation, chemicals or infections or trauma during child-
bearing. Also, she had no alcohol or substance abuse. She
was in good mental state prior to and even after delivery.
Early Childhood
As an infant, he was an easy child to take care of,
easily comforted when seen crying. Primary care was given
by the mother, with the assistance of his relatives from the
father side.. He was breastfed until two years old per
demand basis, although bottle feeding was also utilized
whenever his mother went out of the house for errands. He
first learned to say “na-na”, “ta-ta” at 7 months and he
started to walk at ten months. Developmental milestones
were at par with his age. Toilet and bladder training was
initiated as early as two years old but was mastered at
three, however, with laxity as their comfort room was
situated far from their main house There was no noted
history of head banging, thumb sucking, nail biting, and
temper tantrums.
Middle Childhood
As a child, he was noted to be active and playful
but only within their neighborhood. During this period, he
was observed to prefer playing with children older than his
age.
But most of the time, he stayed at home, playing
alone or with younger siblings. He was more of a follower
and never was he involved into fights. His parents never
inflicted corporal punishment to him although his mother
used verbal reprimands only for his slight misdemeanor.
When he went to school, his daily routine centered
from their house to school and vice versa. He rarely played
with his classmates. The only time he went out of their
house was when he was invited by his paternal
grandmother.
At this time, he used to see his father getting drunk
almost every day. And every time he got intoxicated, he
would go home uttering profanities until he gets to sleep.
But he never hurt his family physically. This was witnessed
by the patient until he reached the pubertal years. But he
never developed fear or hatred towards his father.
Late Childhood
At the age of 13, patient stopped from school and
helped his parents earn for a living by selling “ice drop” in
their place. Later, he learned from his uncle how to drive a
motorcycle and used this skill to also earn money for their
sustenance and for his younger siblings’ schoolings. There
was no sibling rivalry among them.
At the age of 15, he was brought by his uncle to
Morning Breeze and started to earn by driving his own
motorcycle. At the same time, he was also learning to fix
problems with machines of big trucks through his friends,
mostly older than him.
Educational History:
He started Grade I at a nearby elementary school. He was
just an ordinary pupil with an average performance in school. He
was shy and timid and never got involved into school activities. He
was noted to be less participatory in classroom discussion, too.
After graduating from elementary, at the age of 13, he
stopped continuing to secondary schooling. This happened when
they went to the school for enrolment and he was tasked by his
mother to go back to their house to get his report card which the
former forgot to bring with them. Hesitant to go back, he decided not
to push through with the enrolment anymore. Until he lost interest
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EDITOR:
EXIMIUS
2021
in pursuing it and preferred earning money to help his parents who
were also hard up with life for he had two other siblings depending
on them.
Religious History:
Patient was raised as a Catholic and grew up with the
religion but was not devoted to it. He seldom went to church just like
his other family members. His wife and 2 children frequently invited
him to attend mass but he hardly went with them for he feels
awkward bringing with him his two kids beside him and his wife
nagging him at home after coming from mass.
But during his work at the Malacanang, he used to drop by
Quiapo Church every day after coming from work to pray for his
family’s health and security.
Psychosexual History:
He was circumcised at age 15 only after he was kidded by
his friends. His sexual knowledge was through stories from his
friends and few pornographic materials. Through such, he started to
masturbate at the age of 15, though, on rare occasions, sometimes
not even once in a month. He had not witnessed primal scene.
He had his first crush at age 12. He did not pursue courting
the girl although he was aware and informed by his friend that she
also had special feelings for him because he was ashamed he might
be turned down. With this, he always suppressed his feelings
towards girls he admired.
When he was 17 years old, he had his sexual experiences
with different commercial sex workers almost every week spending
P200 for the woman and P300 for the room they went to. He never
practiced safe sex then. He denied acquiring sexually-transmitted
infections during this time. For him, he preferred this set-up for there
was no responsibility attached to it after each contact he had with
the girl until he had a steady relationship a year after. He never
engaged into a homosexual relationship.
Relationship History
When he was 18 years old, he met Joan, of his age, a
garment factory worker boarding next to where he was staying in his
uncle’s house. He courted her and they got steady after less than a
month. They had a harmonious one but the girl was very sensitive to
issues of sexuality. Despite his repeated attempts to have her
engage into sexual relationship with him, the more she declined and
insisted that they should get married first. Their relationship lasted
for a year because she left home to Ilocos and lost contact with each
other.
Then, she met Maricel, who was 2 years his junior. She
was introduced to him by her parents who owned the carinderia
where he used to park while waiting for passengers as tricycle driver.
Maricel was then helping in the carinderia (she was a polio victim
and has gait problem but this was not made known to the patient).
Barely acquainted with each other for 2 weeks, her mother
requested him to look after her for the former is going home to the
province and nobody will be left to accompany Maricel. Having the
chance to be left alone, they engaged into sexual act and got her
pregnant.
On May 23, 1997, they were civilly wed with the support of
their parents. Immediately, thereafter, they lived for free in one of
the rented rooms owned by her parents yet their households were
separated from them. They bore two children, an 11-year-old boy
and a 7-year-old girl. Their relationship went on smoothly despite his
wife’s constant nagging on him especially if he can not give financial
support to her and preferred to give his service for free to his friends
or acquaintances even if they were willing to pay. He just tolerated
his wife and never lifted his hand on her.
Until, sometime in 2005, he got fed up with his wife’s
mouthing against him and he had slapped him once. They ended up
with an irreconcilable fight and he was casted away by his wife. He
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PSYCHIATRY-Case History
0000 National Center for Mental Health, Nueve de Pebrero, Mandaluyong City
Diagnostic Conference, January 14, 2009
went to live with his best friend, Rey, in Novaliches. He continued as
a tricycle driver and never gave financial support to his wife and 2
children. Once, he was approached by his wife for his son’s tuition
fee but he was so stone-hearted that he never gave her any cent.
His wife, on the other hand, went home empty-handed. She then
worked in her parents’ carinderia to sustain her two children’s needs.
They never had communication for a year. He never visited them.
Until, in February 2006, he went home to them and he was readily
accepted by them. Their life went on as if nothing happened and he
remained as a tricycle driver and free-lance automotive mechanic
with no definite income and his wife continued nagging him
everyday.
Legal History
There was no history of arrest or legal suits filed against the
patient.
Substance History:
The patient started drinking alcoholic beverages at the age
of 15 through the influence of his peers or barkada. He used to drink
a bottle of brandy (Fundador) with 4 friends but not until intoxication,
once or twice a month. Later, he shifted to one bottle of beer (Red
Horse) per day after coming from work until he got married when he
had 1-2 occasions per week. He usually drank alone at home. He
stopped 5 years ago after realizing this will not give him anything
good.
He denied smoking and use of any illicit drug.
Current Living Situation
The patient, together with his wife and two children, are
currently living at Morning Breeze, Caloocan City, in her parents’
owned house. The house is located along a slum area. It is a two-
storey, concrete abode with 6 bedrooms at the second floor and the
first floor houses one rented bedroom and the common living room
for the occupants. One bedroom at the second floor is occupied by
the patient’s family and the other 2 rooms are occupied by his
brother-in-law and sister-in-law, respectively. The remaining three
rooms are rented by other boarders. It is well-ventilated and water
comes from NAWASA.
The patient earns for a living by driving his own motorcycle
within the area and on a few occasions, as an automotive mechanic.
They have no fixed daily or monthly income and his wife augments
him by working in her mother’s carinderia.
Family Profile:
1. F.E., 60 year-old, father, part-time PAGASA observer,
does not live with the patient “isang
ulirang ama… di niya kami mapapalaki ng ganito”
2. C.E., 61 years old, mother, housewife, does not live with
the patient
“maganda ang pamamalaki at
pagpapaaral sa amin..”
3. Patient
4. F.E., 27 years old, male, brother, TESDA graduate, does
not live with the patient
“makunat…matipid sa pera..”
5. C.E., 21 years old, female, sister, Chemist, in Bulacan,
does not live with the patient
“mabait…dinadalaw ako lagi..”
6. M.E., 32 years old, female, wife, high school graduate,
lives with the patient
“okay naman…ulirang ina…mabait sa
asawa…marunong makaintindi..”
7. C.E., 11 years old, male, son, Grade V student, lives with
the patient
“mabait na anak… masunurin…”
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EDITOR:
EXIMIUS
2021
8. F.E., 6 years old, daughter, Grade I student, lives with
the patient
“magandang anak…mabait”
Significant others:
1. R.V., 50 years old, male, best friend,
businessman in Novaliches, does not live
with the patient
“mabait…kaya kang ipaglaban kahit
maraming tao…”
2. V.M., 50 years old, female, mother-in-law,
businesswoman, does not live with the
patient
“mabait na biyenan…maintindihin…”
His parents met in Divisoria in 1972 where they both used
to work. He was being paid for writing initials on cartons of produce
bought by merchandisers and she was helping in her family-run
carinderia. He was from Nueva Ecija and she was from Bulacan.
Both of them are high school graduates. After almost five years of
courtship, they became steady for more than a year until they
decided to settle down in 1978. Then, they moved in to Nueva Ecija
and settled in his family’s lot. He worked as a part-time PAGASA
observer and at the same time farming. His mother was a full-
fledged housewife. His parents had harmonious relationship and
seldom had they had petty fights.
Pre-morbid Character:
“mapag-bigay kahit niloloko na”
“parating inaalala ang trabaho”
tahimik”
“palaging kaibigan inuuna”
Course in the ward:
The patient was first examined at the emergency room by
the undersigned. Seen an adult male, poorly groomed and kempt.
He was on loose restraints with blank stares noted. He had poor eye
contact. His affect was blunted. His speech was nonspontaneous,
hypoproductive and in brief phrases. He admitted to hearing voices
“dati po” but no elaborations were given. Later, he just stared at the
interviewer and never answered queries made. He kept on
struggling with his restraints. He was no longer engaged into a
meaningful interview. His impulse control was poor. Physical
Examinations were all within normal limits. He was admitted at ACIS
with an impression of Acute schizophrenia-like psychotic disorder.
Haloperidol 5 mg IM for 1 dose and Biperiden 2 mg prn for EPS were
ordered. Complete blood count and urinalysis were requested.
On his second hospital hour, the patient was first seen by
the PIC at ACIS with note of fever (temp=38.20C). He was referred
to Infirmary for further evaluation and management and was
subsequently admitted as a case PTB V rule out UTI. Complete
Blood Count, sputum AFB for 3 determinations and CXR(PA) done
revealed normal results. Urinalysis revealed Urinary Tract Infection.
He was given Paracetamol, Multivitamins and Cotrimoxazole for
treatment. His febrile episode lyzed and was transferred to Pav1
after 4 days.
On his 5th hospital day, he was seen by the undersigned,
he was clad in blue hospital uniform, medium built, fairly groomed.
He was calm, cooperative, and with fair eye contact. He gave a good
account of himself. He was oriented to 3 spheres. Mood was
euthymic and with appropriate affect. His speech was spontaneous,
normoproductive, relevant, in a soft voice. He had no flight of ideas
or looseness of associations. He narrated his illness started a week
PTA when he had a job in Malacanang and his immediate contact
threatened him to do well with the job. Since then “natatakot na po
ako… di ko alam bakit” He admitted to hearing voices and to
“pakiramdam ko parang may papatay sa amin..” But he denied all
these at the moment. Even homicidal and suicidal thoughts were
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PSYCHIATRY-Case History
0000 National Center for Mental Health, Nueve de Pebrero, Mandaluyong City
Diagnostic Conference, January 14, 2009
negated. He had no recall why he was brought to this center
“natatandaan ko lang kinuha ako ng tatay ko sa bahay.”
He denied any depressive and manic symptom in the past.
He claims “doktora, di naman po ako baliw… alam ko po gusto
nyong sabihin.” He even continued saying “kelan kaya ako lalabas
dito?... May iniwan pa kasi akong gawain sa Malakanyang.”
He admitted to drinking alcoholic beverages since he was
15 years old but stopped 5 years ago “kasi wala naming maidudulot
na maganda.” He denied smoking and use of illicit drugs.
At this time, he had poor insight to his illness. His impulse
control was fair and his judgment was faulty. He claimed to have
good sleep and appetite.
He was started on Haloperidol 5 mg BID and Biperiden 2
mg prn for EPS. Referrals to Dental, social worker and to
psychologist were also ordered. A referral to Male Surgical Infirmary
was also made as he was noted to have anterior neck masses,
bilateral and fine hand tremors.. Further probing on this finding
showed that he had noted the masses a year ago and admitted to
have nervousness, heat-cold intolerance, palpitations and weight
loss of about 25% but did not bother to seek for consult.
On the following day, he was seen by the MSI resident-on-
duty requests for thyroid function test and thyroid ultrasound were
done.
On his 8th hospital day, he was referred to the physician-
on-duty for being disruptive as he was spitting to the personnel and
shouting irrelevancies. He was heedless to advice and had poor
impulse control. He was placed on restraints and given 1 dose of
Haloperidol 5 mg IM with BP precaution. He apparently calmed
down.
The following day, he was interviewed by the undersigned
as he was holding on the grills staring blankly. He had dysphoric
mood. He complained “doktora, bakit ako itinali kagabi, wala naman
akong ginagawang kasalanan? Kelan ba ako makakuwi? Di naman
ako nararapat dito.” He refused to answer questions on him and
insisted on being brought home. He was only pacified when he was
assured that he still has to go for follow-ups with his neck masses.
He had poor insight and impulse control. His judgment remained
faulty. Since Haloperidol was unavailable then, he was shifted to
Chlorpromazine 100 mg at bedtime and Biperiden was continued.
On his 11th hospital day, he was seen by the consultant. He
was behaved and cooperative. His mood was euthymic. He had
relevant speech. He narrated why he got disturbed and restless at
home. He claimed he got tired with his contract at Malacanang and
uttered “masungit kasi yung amo dun.” He is preoccupied with with
his contract of P8,000 there. He denied morbid thoughts at the
moment. He was diagnosed as Brief Psychotic Disorder. He was
transferred to PAV1-W3. Medication was just continued.
On his stay 25th hospital day, he was interviewed by the
undersigned fairly kempt and groomed in his blue hospital gown. He
was cooperative and behaved with adequate eye contact. His mood
was euthymic with appropriate affect. He was noted to have silly
smiles. His speech was spontaneous, normoproductive, relevant
and sof-toned. He claims “maayos na ako doktora…makakauwi na
ba ako?” Kasi may babalikan pa akong gawain dun sa
Malacanang…Wala naman na akong problema na.”
Regarding his condition, he claims ganito lang talaga ako
dok…” Initially, he was reluctant to divulge and kept on denying
about his problem in Malacanang. But eventually he narrated
“naiirita po ako dun kay Resty, sumbong ng sumbong kay Director
na mabagal ang nakuha nyang tao…” “Di naman madaling gawin
yung pinagagawa nya…” “Kaya iniwan ko na lang yun sa iba…”
He denies any perceptual disturbance even prior to
admission. He also denies delusional thoughts but was noted to
have paranoia as he claims “dun pos a amin, di ka sigurado dun,
yung mga galaw ng tao walang katigilan..” He negates any
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EDITOR:
EXIMIUS
2021
depressive and manic symptoms in the past. Morbid thoughts are
negated. Phobias were denied.
At the moment, attention and concentration are intact. He
was able to do simple computations after claiming that mathematics
was his hardest subject at school. He has fair insight to illness and
impulse control. Sleep was adequate and with good appetite.
Medications were continued.
On his 33rd hospital day, patient was seen fairly kempt and
groomed. He greeted the undersigned with a smile and claims “may
student nurse po kasi ako.” He added “doktora, ayos na po ba
findings sa bukol ko?” He was told that he will be brought out by the
Social worker soon to Rizal Medical Center for the examination of
his thyroid function. At this time, he was noted to have euthymic
mood with appropriate affect. His speech was normoproductive,
spontaneous, relevant and audible. He negated any perceptual
disturbance and denied delusional ideations. However, paranoia
was still prominent as he claims “uwi na lang po kami sa probinsya
paglabas ko kasi di ako sigurado dun sa kapitbahay naming sa baba.
Yung mga kaibigan nyang mga kabataan labas-masok sa amin,
yung mga gulong ng sasakyan ko sila siguro kumuha…Wala naming
iba na eh.” He is still preoccupied with his work at Malacanang and
claims “may babalikan pa ako dun, yung bayad, kulang pa..” Asked
if he will still accept the job, “di na po siguro…” “Sa probinsya na lang
andun pa sina tatay…” He denied any suicidal or homicidal thoughts.
He is oriented to 3 spheres and can maintain good eye
contact. He has good memory recall, with fair insight to illness. He
promised to take his medications at home and do monthly follow ups.
Impulse control was fair. He claimed to have good appetite and with
adequate sleep. Current medications were continued.
On his 36th hospital day, patient was brought to Rizal
Medical Center for his thyroid function test. Result arrived three days
after. He was referred to MMI the following day but only emergency
cases were entertained.
On his 42nd hospital day, patient was referred to MMI and
was subsequently admitted. After 2 days, he was transferred back
to Pavilion I with the diagnosis of Ischemic Heart Disease/Coronary
Artery Disease, Diffuse Goiter. He was given the following
medications:
1. ISMN 60 mg/tab, ½ tab OD defer for BP < 90/60 mm
Hg
2. ASA 80 mg/tab, 1 tab OD
3. ISDN 5 mg/tab, 1 tab SL prn for chest pain
4. PTU 50 mg/tab, 1 tab q8 hr
5. Propanolol 10 mg/tab, 1 tab BID defer for CR < 60/min
On his 43rd hospital day, he was fetched and discharged to
his father and the same neuroleptics, anti-thyroid and anti-anginal
medications were advised to continue. He was scheduled for follow-
up after 2 weeks.
On his 1st OPS follow-up (December 11, 2008), he was
seen fairly kempt and groomed, accompanied by his father. He was
cooperative, behaved with good eye contact. His mood was
euthymic with appropriate affect. Speech was spontaneous,
normoproductive and with relevancy. He narrated “doktora, nilagnat
po ako ng umuwi ako…sabi po ng doctor may UTI ako, maayos
naman na po ngayon may antibiotic na po akong iniinom.” When
commented for having gained weight, he answered, “malakas ng
kaunti kain ko…saka walang trabaho, nakapahinga pa..” He still
denied those previous voices he once heard. But he readily admitted
he is living with his parents in Nueva Ecija, “dun na po muna ako
para lumayo sa mga mapaghinala at tsismosang kapitbahay,”
“mahirap po kasi dyan sa amin..marami ang nakikialam..” He denied
any morbid ideation and claimed “maganda nga po ang mabuhay..
may pamilya pa po ako.” He further narrated that he plans to bring
his wife and children to Nueva Ecija after the school year and to
continue working as a tricycle driver “para makabawi sa asawa ko at
mga anak ko dok..”
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 EXIMIUS
PSYCHIATRY-Case History 2021
0000 National Center for Mental Health, Nueve de Pebrero, Mandaluyong City
Diagnostic Conference, January 14, 2009

He now has better insight to his illness and with fair impulse Test Results and Evaluation:
control. His judgment is intact. He was advised to continue his
medications and to consult to a tertiary hospital in their place for the WAIS-R
management of his thyroid problem. Also, he was scheduled for a Verbal Scale IQ =67
follow-up after a month. Performance Scale IQ =63
Full Scale IQ =63
Physical examination and neurological examination: Classification: Mild Mental Retardation

• Conscious, coherent, cooperative, ambulatory Cognitive functioning of the patient is presently appraised along the
• Vital Signs: Mild Mental Retardation level although given the opportunity to exert
o BP- 130/90 mmHg his optimum effort he can still attain a Borderline Dull Normal
o CR- 89 bpm classification.
o RR- 19 cpm
o T- 36.80C Analysis of subtest scores reveals that is ability to profit from past
• Anicteric sclerae, pink palpebral conjunctiva, no experiences, concentration span, facility with numerical operations,
tonsilopharyngeal congestion abstract reasoning, social intelligence, deductive reasoning and
• (+) 4x4 solid, hard,anterior neck masses, bilateral guidance of motor action are all poorly functioning while the
• symmetrical chest expansion, no retraction, clear breath remaining mental faculties are categorized to be affected and
sounds impaired.
• Adynamic pericardium, no murmur, regular rate regular
rhythm Test protocol discloses an emotionally burdened and distressed
• Flat abdomen, normoactive bowel movement, soft, non- person who is unable to effectively confront and resolve his present
tender predicament. He feels helpless, weak and inadequate that further
• Grossly normal, no edema, no cyanosis, 2cm laceration at exacerbates his depression and self-pity which eventually lead to
the left palm entertaining suicidal thoughts and self persecutory ideas. He may
• Neurological examination become withdrawn and isolated that put boundaries with his
Motor: connection and attachment to people.
Left upper 5/5 Right upper 5/5 However, in his desire to strive in meeting his emotional demands,
Left lower 5/5 left lower 5/5 he is prone to be dependent on the affection of others, more so,
Sensory: overdependence, passivity and compliant tendencies. These
Left upper: 100/100. Right upper 100/100 become his way to compensate for his exaggerated search for
Left lower: 100/100. Left lower 100/100 security including his longing to his parental figures so as to indicate
DTR: his need for help and affection. However, superficiality in
Left upper ++ Right upper ++ interpersonal relationships may characterize his social interplay.
Left lower ++ left lower ++
Cranial nerves: Likewise, strong maternal attachment and high regard over her are
CN I - can smell perfume, coffee expressed that leads to inappropriate sexual identification and
CN II - 2-3mm, reactive to light interest on the same sex that at present, still elicits psychosexual
CN III, IV, VI - (+) EOM disturbance and guilt feelings.
CN V - (+) corneal reflex
CN VII - No facial asymmetry Further revealed in his protocol is his attempt/effort to use repressive
CN VIII - can hear sounds defenses in order to maintain his personality against possible,
CN IX, X - (+) gag reflex imminent disorganization. However, when his efforts become vain
CN XI - can shrug shoulders and successful his lack of sensitivity to others surfaces that he
CN XII - no tongue deviation become abrupt, hostile and aggressive with his actions. Low
tolerance for frustrating events coupled with inadequate impulse
Laboratory examination: control will likely unleash his hostility and aggressive defiance of
Complete blood count: Within normal limits authority.
Urinalysis: initially revealed UTI
Repeat Urinalysis Within normal limits He employs defenses such as introjection, repression, acting out
Sputum AFB: No acid-fast bacilli seen and displacement.
CXR(PA): Essentially Normal Chest
UTZ of the thyroid: Enlarged thyroid-bilateral MMPI results yielded an elevation along Scale 6 (Paranoia), Scale 7
Thyroid function test: total T3-elevated (Psychantenia), Scale 8 (Shizophrenia), and Scale 9 (Mania) which
Total T4-elevated further indicates that the Subject is chronically worried, tense and
TSH- decreased agitated. As such, he becomes undecisive and unable to
concentrate that he frequently doubts himself. He has difficulty
forming close interpersonal relationships that he tends to withdraw
Psychological results:
and isolate himself. Such situation further exacerbates his condition
Test administered:
of entertaining obsessive ruminations and thoughts. Moreover,
Weschler Adult Intelligence Scale-R
depressive features are likewise noted specially that he has been
Bender Visual Motor Gestalt test
exposed to severe stress.
Draw a Person Test
Rorschach Psychodiagnostic Test
On the other hand, in his attempt to resolve his affectional longings
Sach’s Sentence Completion Test
due to the absence of parental figures, he is apt to display forced
Thematic Apperception Test
Minnesota Multiphasic Personality Inventory-I

TRANSCRIBERS: P&B
EDITOR: Senpai 5 out of 8
 EXIMIUS
PSYCHIATRY-Case History 2021
0000 National Center for Mental Health, Nueve de Pebrero, Mandaluyong City
Diagnostic Conference, January 14, 2009

and superficial congeniality. This becomes his way of compensating
for his needs for belongingness and acceptance.
However, since his social gratification is merely based on shallow
companionship/acquaintance, he still prone to elicit suspiciousness
that he becomes guarded and overly sensitive to censures. He may
often express his hostility by becoming argumentative and blaming
of others. Likewise he can be impulsive such that outbursts of
temper and inability in delaying his gratification of needs may occur.
Meanwhile, TAT themes mostly elicit delusion of grandeur
specifically being a self-righteous person with narcissistic
accomplishments. Likewise, he has pronounced pre-occupations,
mostly religious in nature in order to combat his guilt feelings and
psychosexual conflicts. Further revealed in his stories is his
continuous longing for maternal parent/environmental support that
usually leads to depression and feelings of abandonment.
Interview with the patients:
Psychodynamics:
Biological
Psychological
Social
A persistent polarity has existed among theories
concerning the origins and the nature of preferred homosexuality.
One major group of theories, including most psychoanalytic
approaches, stresses early developmental contributions and tends
to view homosexuality as psychopathological—a deviation from
healthy and fully mature living. The other major group of theories
assumes homosexuality not to be psychopathological and views
homosexuality as either a spontaneous expression of a natural,
polymorphous sexuality, or as one possible outcome, among many
equally healthy and rewarding outcomes, of social conditioning.
Like in case, R.O. was already conditioned when he was still a
child. He was brought by as a female rather than a male.
Wainwright Churchill wrote in his book titled Homosexual
Behaviorism among Males (New York, 1967). He stated, there are
no sexual instincts in man... human sexuality is entirely dependent
upon learning conditioning. The individual's pattern of sexual
behavior is acquired in the context of his unique experiences and in
no sense innate or inherited.
and sex, not wanting to "betray" his mother or re-experience his
guilt.
When he realized that he was adopted, he repressed his
depression he felt, and aside from the hatred from the parents he
hated himself for being adopted though he wasn’t able to express
his anger it come out to different ways like to prohibited drugs.
Having this kind of set up, R.O. felt betrayed by his mother’s secrecy
of his identity and abandoned by his real father.
His excessive sex was part indentification to his mother
philandering attitude and his longing for a partner. And in order to
prove his worth to other people and to his peers, patient joined
beauty pageants to assure himself that like his mother he can be
attractive and can be sought after by different men. He even went
further by having his breast augmented.
R.O. was also religiously pre-occupied to hide his guilty
feeling of his homosexuality.
Such early life events created a heightened vulnerability to
subsequent stressors. Biologically, such painful events may have
sensitized receptors sites, such that ideas and images associated
with depressive trends would ultimate act as condition stimuli
capable of eliciting depression. Manic defenses such as grandiosity,
denial, contempt, and idealization developed as response to painful
affects. According to Melanie Klein mania is a defensive reaction to
depression, this is what happened to my patient, his disappointment
over father’s abandonment and mother’s betrayal whom he identified
as a child rekindled his feeling of worthlessness thus succumb to
psychosis.
Salient features:
Differential diagnosis:
1. Mental and behavioral disorder secondary to General
Medical condition
2. Personality disorder, Not otherwise specified
3. Schizoaffective disorder
4. Bipolar affective disorder, depressed episode with
psychotic symptoms
5. Mental disorder secondary to substance use
(Methamphetamine)
6. Bipolar affective disorder, mixed episode with psychotic
symptoms
7. Bipolar affective disorder, manic episode with psychotic
symptoms

The weight accumulated indicates that homosexuality results from Diagnosis:

adverse life experience. In a preponderance of cases an abnormal
relationship between both parents and the child have specific and ICD 10 F31.2 Bipolar affective disorder, current manic episode with
identifiable themes. Most mothers of patients were over close and psychotic symptoms
inappropriately intimate with the homosexual son who was ICD 10 F15.21 Amphetamine dependent, currently abstinent, but
preferred to his siblings and to his father. These mothers spent a in a protected environment
great deal of time with this son and they were mostly over
controlling, over protective, and infantilizing, thus interfering with DSM IV 296.44 Bipolar 1 disorder, most recent episode manic,
the development of self assertiveness and independence. They severe with psychotic symptoms
were over concerned about disease and injury and they promoted
in the child a self image of frailty and non masculinity. R.O. mother DSM IV 304.40 Amphetamine dependence with psychological
has a strong personality who conditioned him to be a girl since birth dependence, in a controlled environment
where he was dress as girl. While his father’s dependent
personality whom he didn’t identify when he was a child, thus Mutiaxial evaluation:
identified the female sex more than the male sex. Threaded such
pathway and which was heightened to his closeness to female and Axis I 296.44 Bipolar 1 disorder, most recent episode
gay males friends. Having introjected the strong persona of the manic, severe with psychotic symptoms
mother and having a weak father brought the patient to identify to 304.40 Amphetamine dependence with
the female role. He may then experience sexual attraction for his psychological dependence, in a controlled
mother, which leads to extreme guilt and repression of a normal environment
sexual drive toward women. He might then turn to men for intimacy

TRANSCRIBERS: P&B
EDITOR: Senpai 6 out of 8

PSYCHIATRY-Case History
0000 National Center for Mental Health, Nueve de Pebrero, Mandaluyong City
Diagnostic Conference, January 14, 2009
Axis II None
Axis III None
Axis IV Family problems
Financial problems
Relationship problems
Lack of family support system
Axis V Initial 21-30
Current 70-80
DSM-IV-TR criteria:
Bipolar affective disorder
A. A distinct period of abnormally and
persistently elevated, expansive, or irritable
mood, lasting at least 1 week (or any duration
if hospitalization is necessary)
B. During the period of mood disturbances, three
(or more) of the following symptoms have
persisted (four if the mood is only irritable) and
been present to a significant degree:
1. inflated self-esteem or grandiosity
2. decrease need for sleep
3. more talkative than usual or pressure to keep
talking
4. flight of ideas or subjective experience that
thoughts are racing
5. distractibility
6. increase in goal-directed activity or
psychomotor agitation
7. excessive involvement in pleasurable
activities that have a high potential for painful
consequences
C. The symptoms do not meet criteria for mixed
episode
D. The mood disturbances is sufficiently severe
to cause marked impairment in occupational
functioning or in usual social activities or
relationships with others, or to necessitate
hospitalization to prevent harm to self or
others, or there are psychotic features
E. The symptoms are not due to the direct
physiological effects of a substance or a
general medical condition
Substance dependence
A maladaptive pattern of substance use, leading to
clinically significant impairement or distress, as manifested by three
(or more) of the following occurring at any time in the same 12-month
period
1. Tolerance, as define by either of the following:
(a) a need for markedly increased amounts of the
substances to achieve intoxication or desired effect
(b) markedly diminished effect with continued use
of the same amount of the substance
2. Withdrawal, as manifested by either of the foloowing:
(a) the characteristic withdrawal syndrome for the
substance
(b) the same (or closely related) substance is
taken to relieve or avoid withdrawal symptoms
3. The substance is often taken in large amounts or over a
longer period than was intended
4. There is persistent desire or unsuccessful efforts to cut
down or control substance use
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5. A great deal of time is spent in activities necessary to
obtain the substance, use the substance or recover from its effects
6. Important social, occupational, or recreational activities
are given up or reduced because of the substance use
7. The substance use is continued despite knowledge of
having a persistent or recurrent physical or psychological problem
that is likely to have been caused or exacerbated by the substance.
Specify if:
With physiological dependence
Without physiological dependence
Course specifiers:
Early full remission
Early partial remission
Sustained full remission
Sustained partial remission
On agonist therapy
In a controlled environment
Discussion:
Mood disorders encompass a large group of disorders in
which pathological mood and related disturbances dominate the
clinical picture. Patients with an elevated mood demonstrate
expansiveness, flight of ideas, decrease sleep, heightened self-
esteem, and grandiose ideas. All these symptoms were present in
the case.
Bipolar I disorder has a life time prevalence rate of 1%,
similar to the figure of schizophrenia. It has an equal prevalence rate
among men and women. Its onset ranges from childhood, as early
as age 5 or 6, to 50 years old, with the mean age of 30. And it is
more common among divorce and single persons.
Many studied have reported that abnormalities in the
biogenic amines metabolite like 5-HIAA, HVA, MHPG, in the blood,
urine and CSF of patients with mood disorders.
Genetic data suggest that a significant genetic factor is
involved in the development of a mood disorder, but the pattern of
inheritance is complex. A genetic component plays a more
significant role in transmitting bipolar I disorder than major
depressive disorder. Family studies have repeatedly found that first-
degree relatives of bipolar probands are 8-18 times more common
that any other mood disorders. The inheritability of bipolar I disorder
is also apparent in the fact that about 50% of all bipolar I disorder
patients have at least one parent with a mood disorder, most often
major depressive disorder. Just like the case of my patient, his family
profile has a strong inheritance of mood disorder. Although not
properly documented, but history revealed that the mother suffered
a depressive symptoms after giving birth to the patient.
In diagnosing a patient with bipolar I disorder, DSM IV TR
criteria should be followed. A distinct period of abnormally and
persistently elevated, expansive or irritable mood, lasting at least 1
week and must have three or more symptoms listed in the criteria B
that persist. In my patient, onset of symptoms was observed more
than month prior to admission. He fulfilled criterion A and has
presented 5 out of 7 symptoms listed in criterion B. Mixed episodes
can not be totally ruled out.
Bipolar I most often start with depression (75% in women,
67% in men) and is a recurring disorder. Most patients experience
both manic and depressive episode. The manic episodes typically
have a rapid onset, but may evolve over a few weeks. Bipolar I
disorders with early onset is associated with poor prognosis.
Amphetamines are the most widely used illicit drugs,
second only to cannabis. Methamphetamine is a pure form that
abusers of the substance inhale, smoke, or inject intravenously. Its
psychological effects last for hours and described as particularly
powerful. The classic amphetamine drugs exert their major effects
through the dopaminergic system. Some designer drugs have
effects on both serotonergic and the dopaminergic system and have
Senpai 7 out of 8
 EXIMIUS
PSYCHIATRY-Case History 2021
0000 National Center for Mental Health, Nueve de Pebrero, Mandaluyong City
Diagnostic Conference, January 14, 2009

a behavioral effects that reflects a combination of amphetaminelike The third stage is when the person indulges into an homosexual
and halucinogenlike activities. They have pronounce effect on our life-style, beginning a process of dependency on homosexual sex
brain reward pathways that addicts would have a positive reinforcing and on the homosexual life- style.
effects of drugs resulting to drug seeking behavior.

Management:
The treatment of mood disorder must be directed toward
several goals. First, the patient’s safety must be guaranteed.
Second, a complete diagnostic evaluation of the patient must be
carried out. Third, a treatment plan that addresses not only the
immediate symptoms but also the patient’s prospective well-being
must be initiated.
Lithium, Divalproec Na, Olanzapine are standard treatment
approached for manic phase of bipolar disorder, but Carbamazapine
is also a well-established treatment.
The patient was initially given Haloperidol 10mg, but later
shifted to Risperidone 1/2mg tab BID and additional Divalproec Na
250mg BID was prescribed.

End notes!!!!
Gender-identity is an awareness of one's masculinity or feminity. In
homosexuals, there is a feeling of inadequacy and incompleteness
in the inner essence of their being. Therefore, they search for the
missing part of themselves in another person. Through a sexual
contact or union with another person of the same sex, they feel, at
least momentarily, whole and more complete.

In most cases, homosexual thoughts and feelings originated in

preadolescent experiences. Therefore, it is basically a non-sexual
condition. The homosexual love need is essentially a search for
parenting. What the homosexual seeks to fulfill are normal needs
for bonding that have been abnormally left unmet in the process of
growth. That is, a man is looking for his father's love through other
men, and a woman is looking for her mother's love through other
women. Therefore, the drive is one of reparation, seeking to heal
the unmet love needs of the past.

In the case of female homosexuality, she may have been abused

either by her father or another man or men in her life. The abuse
could have been sexual, emotional, mental or physical. This leaves
her deeply traumatized by men. An not wanting to experience the
memory of abuse, she turns to women for comfort, love and
understanding.

In the case of the male homosexual, there may have been an

abnormally close mother- son attachment. In a marriage where the
mother's emotional and physical needs are not met by her
husband, she may turn to her son for emotional comfort and
support.- This generally is not done with conscious intent to hurt,
but nonetheless, it has profound and damaging effects upon the
psychosexual development of the son. He may overidentify with his
mother and feminity and dis-identify with his father and masculinity.

Later in puberty, this son may then experience sexual attraction for
his mother, which leads to extreme guilt and repression of a normal
sexual drive toward women. He might then turn to men for intimacy
and sex, not wanting to "betray" his mother or re-experience his
guilt. This process is generally unconscious.

If we look more deeply into the causes of homosexuality, we can

find that they develop in three stages : the root of homosexuality is
to be found in early childhood. The second stage begins with
puberty, when the "homo-emotional" unmet needs are erotized.

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EDITOR: Senpai 8 out of 8