PRESENTATION CASE

NON-PSYCHOTIC
WILA FAJARIYANTIKA
20110310129

Supervisor :
dr. Sabar Parluhutan Siregar,
Sp.KJ

Patients Identity
Name

: Ny. W
Age
: 35 years
Religion
: Muslim
Address
: Wates, Magelang
Job
: Entrepreneur
Marital Status
: Marriage
Education Status : SMA

PSYCHIATRIC
HISTORY

Chief Complaint
Patient come to control to the
polyclinic of psychiatry RSJS
Magelang because patient still
suddenly feeling worried without
any reason, chest pounding and
cold sweat followed by headache
but not too disturbing her daily
activity as entrepreneur and
house wife.

Stressor
Undefined

History of Present illness

November 2014
Patient had problems with her husband. Her husband is a
sailor who rarely go home and rarely give money to the
patient, causing the patient a lot of debt This causes the
patient to be sleeplessness, headaches, chest pounding, cold
sweat. Patient went to the doctor to examine complaints.
February 2015
Patient came again with more complaint. Her husband often
angry nearly every day without any reason. So patients
become palpitations shortness of breath, nausea and
vomiting. So all the activity is distrubing because all of her
complaint.

Oktober 2015
Patient come to the doctor to control because of run out the
medication. Patient sometimes hard to sleep and still feeling
worried, chest pounding and sweat without any reason but
not as hard as before. According to the patient, the husband
is not too angry like before so it decrease the patient
symptom and the activity going to normal.

History of Past illness

History of
Pshyciatric

General
Medical
History

The patient has never experienced a mental disorder

earlier

Infectious disease history (-)

History of trauma (-)
History of seizures (-)

History of
Smoking
and
NAPZA

Patients smoked since high school and smoked a

proximately 1 pac 2 days

History of
Previous
Psychiatric
Disorder

No history of previous psychiatric disorder

History of
Personal Life

PRENATAL & PERINATAL

The patient is a foster child, the patient raised by
adoptive parents since the age of 3 years, the patient
is often met with biological father but had never met
her biological mother.
There was no valid data about prenatal history and
mother pregnancy and delivery, length of
pregnancy, spontaneity and normality of delivery,
birth trauma, whether the patient was planned or
wanted, and also any birth defect, how mothers
condition, and who was help of labor.
There was no valid data about the condition of
patient when she was born such as activity (muscle
tone), pulse, grimace (reflex irritability), appearance,
and respiration (APGAR score)
There was no valid data about feeding habits of
patient, is it breast feed or bottle feed, was he
having any eating problem.

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
No Valid Data

Normal range
0-3 months

No Valid Data

3-6 months

No
No
No
No

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

Valid
Valid
Valid
Valid

Data
Data
Data
Data

No Valid Data

36-48 months3

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
No Valid
Data
No Valid
Data
No Valid
Data
No Valid
Data
No Valid
Data
No Valid

Normal range
3-6 months
6-9 months
9-12 months
12-18 months
18-24 months
24-36 months
36-48 months

Developmental History (Language)

Ability

Result

Normal
range

Oooh-aah

No Valid
Data

0-3 months

Turning toward the sound

No Valid
Data

3-5 months

High-pitched sound

No Valid
Data

3-6 months

Voice without meaning (mamama,

Bababa)

No Valid
Data

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

No Valid
Data

24-36 months

Developmental History (Social &

Personal)
Ability

Result

Normal range

Know their mother

No Valid Data 0-3 months

Reach out

No Valid Data 3-6 months

Clap

No Valid Data 6-9 months

Playing peek a boo

No Valid Data 6-9 months

Know their family

No Valid Data 9-12 months

Appoint what her wants

without crying or whining

No Valid Data 12-18

months

Tidy up toys

No Valid Data 24-36

months
No Valid Data 36-48
months

Playing with friends, follow

the rules of the game

There are no valid data

about feeding habits of
patient (breast feeding or
bottle feeding).

There is no valid data on

when patient started
bubbling (6-9 month)

There are no valid data

about psychomotor like when
head up (3-6 month), face
down (3-6 month), sit down
(6-9 month), crawl (6-9
month), walking (6-9 month),
running (9-12 month),
holding something.

There are no valid data

about psychosocial likes
starting to smile when meets
other peoples (3-6 month),
shocked when hear
something (3-6 month), when
the patient first laugh or
squirm when asked to play,
nor playing claps with others
(6-9 month)

There are no valid data

about Emotion of patients
reaction when playing,
frightened by strangers,
when strating to show
jealousy or
competitiveness towards
other and toilet training.

There are no valid data

on when the patient first
copied sounds that were
heard, or understanding
simple orders.

There are no valid data

about cognitive which age
the patient can follow
objects, recognizing her
mother, recognizing her
family members.

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 (NO VALID DATA)
There was no valid data on patients gender identification,
interaction with his surrounding. There were no data on when
patient first entered primary school, how well patient handle
separation from parents, how well she plays with new friendson
first day of school
Communication (NO VALID DATA)
There was no valid data regarding patients ability to make
friends in school, and how many friends patient have during
her schooling period.
Emotion (NO VALID DATA)
No valid data on patient adaptation under stress

Sexual Development Sign and Activity (NO VALID

DATA)
No data on when patient first menarrche, 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 ( NO VALID DATA)
No valid data on when and how patients relationship with
different gender, if patient ever had any relationship with
opposite gender.
Communication (NO VALID DATA)
No valid data on how well the relationship between patient
with parents and other family.
Emotion (NO VALID DATA)
No data if patient ever told friend or family regarding any
problems
No data if patient attempted to break the rules (truant school

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 her 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

School Aged
Physical

Cognitive

Social

Slow, 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 acommunication

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

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

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, intercourse,
sexual wearing, look for
nude pictures in books,
magazines
10-12 yr: games with peeing,
sexual activity (e.g., strip
poker, truth/dare, boy-girl
relationships, flirting, some
kissing, stroking/rubbing,
reenacting intercourse with
clothes on)

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

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 overreact 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

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

ADULTHOOD
Occupational History
Patients an entrepreneur

Marital Status
Patients were married and now have 2 children

Religious History
Patient are muslim when raised by his biological parents,
patients were katholik

Law lesness and military history

Patients never violated the law and militer

Psychosexual History
Since childhood, the patient should be have and dress
other girls. Patient are aware of her woman. Patients
married to a man according to his own choice.

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

Family History
The

family of the patients father

is suffering from a mental
disorder but the patient does not
know for sure

Genogram

Progression of illness
Symptoms

Nov 2014

Role
Function

Feb 2015

Okt 2015

MENTAL STATE (October, 23th

2015 at 14.00 am)
Appearance
A women, appropriate to her 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
Decrease
Quality
:
Decrease

BEHAVIOUR
Hypoactive
Hyperactive
Echopraxia
Catatonia
Active negativism
Cataplexy
Stereotypy

Normoactive

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
Appropriate
Restrictive
Blunted
Flat
Labile

Disturbance of Perception
Hallucination

Auditory
Visual
Olfactory
Gustatory
Tactile

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

Depersonalization (-)

Illusion

Auditory
Visual
Olfactory
Gustatory
Tactile

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

Derealisation (-)

Thought Progression
Quantity

Logorrhea
Talk active
Remming
Blocking
Mutism

Quality
Irrelevant answer
(-)
Incoherence
(-)
Coherent
(-)
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 (-)

of Persecution(-) Delusion of Perception (-)

Thought of Echo (-)
Delusion of Reference (-)
Thought Insertion (-)
Delusion of Envious (-)
Delusion

Thought of withdrawal(-)
of Hypochondria (-)
Delusion of magic-mystic (-) Thought Broadcasting (-)
Delusion

Fantasy

(-)

Form of Thought
Realistic
Non Realistic
Dereistic
Autistic (+)

Impulse Control When

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

Insight
Impaired insight
Intellectual Insight
True insight (+)

Sensorium and Cognition

Level of education
: SMA
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
: Good

Physical Examination
General physical examination :
General Appearance : Compos Mentis
Vital sign
Bp: 130/70 mmHg
HR : 107x/Minute
To : 36o C

RR

: 20x/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 :

Interpretation
NORMAL

Cranial Nerves Examination

Interpretation :

Significant Finding Resume

A women, 35 years old, married,foster child, patients often fell worried and
sleeplessness. The family of the patients father is suffering from a mental
disorder
Symptoms
Headaches
palpitations shortness of
breath
chest pounding
cold sweat
nausea and vomiting
can not perform the
usual activities.

Mental status

Mood: Disforik
Form of Thought:
Autistic

Impairment

none

Syndrome
Syndrom Mild Depressive
Episode

Syndrom General Anxiety

Disorder

Patient often Feel weakness

Insomnia

Patient often feel worried

Palpitations shortness of breath
Chest pounding
Cold sweats
Headache
Nausea and Vomiting

DIFFERENTIAL DIAGNOSIS
F41.1

General Anxiety Disorder

F41.2 Mixture of Anxiety and
Depression disorder

F41.2 Mixture of Anxiety and Depression disorder

Diagnostic criteria can be enforced by using diagnostic guidelines based on PPDGJ III

DIAGNOSTIC GUIDELINES
There are symptoms of anxiety or depression,

IN PATIENT
Fulfilled

which each show a secros of symptoms that are

not severe enough to make a diagnosis in it self.

For anxiety, some autonomic symptoms must be
found, although not continous, in addition to
anxiety or excessive worry
If there is severe anxiety a companied buy

Fulfilled

depression

which

considered

is

lighfer,

category

of

it

should

other

be

anxiety

disorders, or phobic anxiety disorder.

If there is depression syndrome and severe

Fulfilled

anxiety enough to enforce each diagnosis, then

both diagnoses should be presented, and the
diagnosis of the mixture can not be used. If for
any reason can be put forward only one diagnosis
then depressive disorder should take precedence.
When these symptoms are closely related to the
stres of life is clear, then it should be used F43.2
adjustment disorder category

Fulfilled

MULTIAXIAL DIAGNOSIS
AXIS I

F41.1 General anxiety disorder

AXIS II

Z0.32
AXIS III

AXIS IV

Family Problem | Romance Problem

AXIS V

GAF 40 (Admission) | GAF 70 (Latest)

PROBLEM RELATED TO THE

PATIENT
Problem about patients biological state
(organobiology)

There was an abnormality in increase norepineprin

Problem about patients mental state
(psychology)
Anxiety disorder found by frightened and worried in the
patients. Motoric tension is shown by worried feeling and
headache, otonomic nerve overacivity is shown with
hiperhidrosis excremity, chest pounding, and palpitations
shortness of breath, so patient needs psychotherapy.
Problem about patients life (social)
Patient is found mild hendaya in the social and occupation
status so patient needs sosioterapi.

PLANNING MANAGEMENT

Responsive

Phase
The target of therapy was 50% decrease symptoms
Anti-anxiety

Clobazam 0,5 mg 2x1

Clobazam has sedative and calming effect, so that was a
reason why given at night
o Haloperidol 0,5 2x1
Haloperidol can address issues that affect way of thinking,
feeling, or behaviour as haloperidol serves to inhibit the effects
of chemicalsin the brain.
o

Remission

Phase
The target of therapy was 100% remission of symptoms
o Continue the pharmacotherapy
Psycotherapy
a.

b.

:
Cognitive therapy, where patient teach for know and
assess his worried thought with purpose to find alternative
thought which can be distract the focus and can assess
pratically.
Relaxation technic : asumption is mental relaxation is
followed with physical relaxation

c.

Anxiety management training,

according to rasionalize that
worried is controlled by control
circle of anxiety which make
problem more. This way is done
with explanation about anxiety,
that have consequency.
Relaxation training, breath therap
if needed, can followed with this
therapy.

Recovery Phase

Target therapy was 100% remission of

symptoms
The
patient
must
be
taking
medication regularly and control to
psychiatric

Family Education : to give the

explanation with
patient family
especially for the husband so he
can give more attention to his wife
to fasten the medication.

PROGNOSIS

Quo
Quo
Quo

ad
ad
ad

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

THANK YOU