CHAPTER I

PRELIMINERY

1.1 Background
The Soul Medicine Block and the Sublime Function are the fourteenth
block in fifth semester of the Competency Based Curriculum of Doctor
Education Faculty of Medicine, Muhammadiyah University of Palembang. In
addition, as we know that the learning program in this UMP FK uses KBK
learning system, so it is expected that doctor graduates from FK UMP
become doctors who are able to understand the existing systems in the human
body.

1.1. Purpose and objectives

The purpose and objectives of this case study tutorial, namely:
1. As a report task group tutorial that is part of KBK learning system at the
Faculty of Medicine, Muhammadiyah University of Palembang.
2. Can solve the case given in the scenario with the method of analysis and
learning group discussion.
3. Achieving the objectives of the tutorial learning method.

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 CHAPTER II
DISCUSSION

2.1 Tutorial Data

Tutor : dr. Rizki Dwiryanti
Moderator : Savira Chairunnisa
Secretary Desk : Betry Monica
Secretary Board : Topan Dwi Setiawan
Run time : Monday, September 16th 2019 (tutorial stage 1)
At 08.00-10.30 PM
Wednesday, September 18th 2019 (tutorial stage 2)
At 08.00-10.30 PM

Rules:
1. Switch the phone off or in silence.
2. Raise your hand when going to argument.
3. Permission when going out of the room.
4. Relax and watch as the tutor gives directions.
5. During the tutorial takes care of attitude and speech

2
2.2 Scenario

“Stop Mochking me”

Nassar, a 30 years old brought to the emergency departement due to

disturbing the neighborhood since one month ago. According to his mother,
approximately 8 month ago, right after Nassar cancelled marriage, the patient
started to daydreaming and withdrawing from society. The patient starting to
indolently going out and talking less with his family.

Six month ago, the patient starting to shows a change of personality. The
patient believe that the neighbors were mocking him behind his back. The patient
also didn’t want to go the local market because he believes that the seller also
mocking him. Nassar started to eat less, seldomly takes bath, and his daily activity
was watching television.

On the previous month, the patient won’t go out from his home, because
he believes that the neighbors are plotting to harm him. Every time there was
someone who passes through his home, he always throws some stone and shouts
“Don’t disturb me! Go away!”. The patient also threatens his father with machete,
because he believes that his father was trying to kill him. He seldomly sleep sleep,
and everynight he always patroliing around the house to check whether there was
someone who wants to harm him. The patient didn’t want to take care of himself,
and only eats when being told.

Before this complaint, Nassar was known as a smart student in school, and
tend to be perfectionist. Nassar used to be a civil servant, but he didn’t went to
work since two month ago because of his fear of going out. Nassar was the only
child and came from a middle-class family. Nassar was known to had a causin
who suffers the same symptom and was hospitalized because of it.

Autoanamnesis :

3
During the interview, the patient tends to be rowdy, anxious and not cooperative
on answering the question given. The patient tends to be angry when being asked
and tries to evict the examiner.

Premorbid history :
Baby : being fed with breast milk untill 6 month old, and continued with
formulated milk due to his mother jobs.
Chilhood and adolescence : jolly, had a lot of friend, parenting : authoritarian
mother with permissive father
Early adult : jolly with a lot of friend

Education history :
Elementary school, junior high, senior high, university : high achieving student
who always be the best ten of his class

Medical history :
There is no history of head
There is no history of NAPZA
There is no history of fever
There is no history of other medical condition

Physical examination :
Awareness : disturbed compos mentis; blood pressure 110/80 mmHG, pulse 84
x/m, RR 20 x/m, temp 36,7° C, nutritional status BW 60 kg, BH 160 cm

Pryciatry status :
Appearance : medium postured patient, lack of self care, eye contact with the
interviewer are exist.
Attitude and behavior : not cooperative and agitative
Speaking : fluent verbalization
Mood : hypertimic and unstable

4
Affect : inappropriate
Thought : not realistic, irrelevant, incoherent, delusion (+)
Perception disorder : auditoric hallucination (+), illution (+)
Intelligence : memory is normal, there is no amnesia
Time-place orientation : normal
Reality testing ability : disturbed
Insight : first grade
Judgement : disturbed

2.3 Term of clarification

No Clarifications Meaning
11 Hypertimic Excessive emotionalism
Motorized and cognitive activities or anxiety
2 Agitative that are not purposeful and excessive,
usually associated with anxiety
External expressions of emotions that are
3 Affect
tied to ideas or mental images on objects
Someone who often makes a fuss or usually
4 Rowdy
triggers problems
5 Mood Emotional state or mood state of a person
6 Amnesia Pathological memory disorders
Sensory perception (vision, touch, hearing,
7 Hallucination
taste) without any external stimulus
(waham) false and idiosyncratic beliefs of
8 Delusion people who are constantly upheld even
though there are facts that cannot be refuted
9 Anxious Feeling worried or nervous
mentally ill mainly due to traumatic or
10 Disturbed
unpleasant experiences
Patterns of mental images that are formed
11 Attitude
from a collection of experiences in other

5
 times
The attitude or behavior of each or all of a
12 Behaviour person's total activities especially those that
can be observed from the outside
changes in the way a person thinks, feels and
13 Change of personality behaves that are characteristic of a person,
are relatively fixed, and can be predicted.
Belief that a person to achieve the best
14 Perfectionis
condition in physical or non-material aspects
15 Premorbid occur before the disease develops
relates to examining observable symptoms
16 Psyciathri status and behavior compared to underlying
psychodynamic processes
17 Unstable lacking stability or fixity or firmness
Thoughts that are generally
18 Inkoheren incomprehensible, thoughts or words that
come out without logical connection.
the act of compiling, recognizing, and
interpreting sensory information in order to
19 Perseption
provide an overview and understanding of
the environment
vigilance and understanding of sufferers
about attitudes, feelings, behaviors and
20 Insight
symptoms that interfere; self
understandingza
aspects of the ability of patients in social
21 Judgement
considerations

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2.4 Problem Identification.

1. Nassar, a 30 years old brought to the emergency departement due to

disturbing the neighborhood since one month ago.
2. According to his mother, approximately 8 month ago, right after Nassar
cancelled marriage, the patient started to daydreaming and withdrawing
from society. The patient starting to indolently going out and talking less
with his family.
3. Six month ago, the patient starting to shows a change of personality. The
patient believe that the neighbors were mocking him behind his back. The
patient also didn’t want to go the local market because he believes that the
seller also mocking him. Nassar started to eat less, seldomly takes bath,
and his daily activity was watching television.
4. On the previous month, the patient won’t go out from his home, because
he believes that the neighbors are plotting to harm him. Every time there
was someone who passes through his home, he always throws some stone
and shouts “Don’t disturb me! Go away!”. The patient also threatens his
father with machete, because he believes that his father was trying to kill
him. He seldomly sleep sleep, and everynight he always patroliing around
the house to check whether there was someone who wants to harm him.
The patient didn’t want to take care of himself, and only eats when being
told.
5. Before this complaint, Nassar was known as a smart student in school,
and tend to be perfectionist. Nassar used to be a civil servant, but he
didn’t went to work since two month ago because of his fear of going out.
Nassar was the only child and came from a middle-class family. Nassar
was known to had a causin who suffers the same symptom and was
hospitalized because of it.
6. Nassar was known to had a causin who suffers the same symptom and
was hospitalized because of it.
7. Autoanamnesis :

7
 During the interview, the patient tends to be rowdy, anxious and not
cooperative on answering the question given. The patient tends to be
angry when being asked and tries to evict the examiner.

Premorbid history :
Baby : being fed with breast milk untill 6 month old, and continued with
formulated milk due to his mother jobs.
Chilhood and adolescence : jolly, had a lot of friend, parenting :
authoritarian mother with permissive father
Early adult : jolly with a lot of friend

Education history :
Elementary school, junior high, senior high, university : high achieving
student who always be the best ten of his class

Medical history :
There is no history of head
There is no history of NAPZA
There is no history of fever
There is no history of other medical condition
8. Physical examination :
Awareness : disturbed compos mentis; blood pressure 110/80 mmHG,
pulse 84 x/m, RR 20 x/m, temp 36,7° C, nutritional status BW 60 kg, BH
160 cm.
9. Pryciatry status :
Appearance : medium postured patient, lack of self care, eye contact with
the interviewer are exist.
Attitude and behavior : not cooperative and agitative
Speaking : fluent verbalization
Mood : hypertimic and unstable
Affect : inappropriate

8
 Thought : not realistic, irrelevant, incoherent, delusion (+)
Perception disorder : auditoric hallucination (+), illution (+)
Intelligence : memory is normal, there is no amnesia
Time-place orientation : normal
Reality testing ability : disturbed
Insight : first grade
Judgement : disturbed

2.5 Problem Analysis

1. Nassar, a 30 years old brought to the emergency departement due to

disturbing the neighborhood since one month ago.
a. What is the anatomy and fisiologi in this case?

Limbic system :

A system that emphasizes a particular motivation or goal-oriented

behavior, directly aimed at the maintenance of homeostasis and
survival of individuals and species. (Nieuwenhuys, 1996)

Function:

 maintenance of homeostasis
 Motivated and goal
 Oriented behavior
 The survival of the individual
 Survival of the species
 Learning and remembering

The structure of the limbic system:

1. thalamus

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 Thalamus is the part of the brain responsible for detecting and
convey information from our senses, such as smell and sight.
Thalamus shape resembling two avocado rolled into one, the
pieces are in the right hemisphere of the brain, and one was in
the left hemisphere. This thalamus located in the brain stem,
and is part of the flow of information into the brain, which is
part of the brain responsible for thinking and movement. In the
thalamus there are also Projection Fibers, a collection of axons
from the cell soma located in one part of the brain and has the
ability to synapsed with neurons in other parts of the brain.
Projection fibers helps projecting or transmitting messages
(sent via synapses) to the cortex. (Hapsari et al, 2014)
2. The hypothalamus
The hypothalamus is a crucial part of the limbic system is
responsible for producing some chemical messengers, called
hormones. These hormones control the water content in the
body, sleep cycles, body temperature and food intake. The
hypothalamus is located below the thalamus. The
hypothalamus is divided into:
 The hypothalamus Anterior: Set thirst and sexual
activity
 Posterior hypothalamus: Set the temperature and smell
 Lateral hypothalamus: Set hunger
 The hypothalamus Ventra: Set the hormone synthesis
 Ventromedial hypothalamus: Set satiety
3. Amgydala
One of the two almond-shaped groups of neurons in the
temporal (side) lobe of the cerebrum. Both the amygdala is
responsible for preparing the body for emergency situations,
such as being 'shocked', and to store memories for the
introduction of future events. The amygdala helps in the

10
 development of memories, especially those associated with
emotional events and emergencies. The amygdala is also
involved specifically with the development of the emotions of
fear, and can cause extreme expression of fear, as in the case of
panic. In addition, the amygdala plays a major role in pleasure
and passion generative, and help manage the response "fight or
flight" in survival. Observation of the amygdala activates the
expression of emotion, the amygdala turned out to provide a
response to the need of the process of emotional expression.

4. Hipocampus
Other parts of the temporal lobe is responsible for converting
short-term memories into long-term memory, for example, can
provide stimulation in the form of rehearsal (repetition). In
addition hippocampus can also function as a navigation room,
for example, we can memorize the route from home to the
office. The hippocampus is thought to work by the amygdala to
memory storage, and damage to the hippocampus can lead to
amnesia (loss of memory).
5. Basal ganglia
Set of neuronal cell bodies responsible for coordinating muscle
movement in the posture that is located in the anterior portion
of the lateral Ventrikal. Motor control, where the movement
began, took place and ended as expected, coordinated by the
basal ganglia.
The main structure of the basal ganglia are the caudate,
putamen, and globus pallidus.

1) Caudate

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 It looked like a tail, located extending out from each of the
amygdala, the first thing kea posteriorly and anteriorly,
respectively caudate hapir full circle.
2) Putamen
It is the middle kaudatus.kaudatus and putamen are
connected by a series of bridges and putamen
serabut.Kaudaus both of them have the same
characteristics, which has the form of stripes or lines known
as the striatum (striped structure lines).
3) Globus pallidus
Circular structure that pale colored, medial putamen diarah
location, between the putamen and thalamus.

Neurohormonal settings:

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Neurohormonal systems in the human brain that plays a role consists of
four systems:

1) Locus ceruleus and norepinephrine systems

Locus ceruleus is bilateral and posterior side of the connection
between the punch and mesensefalon.Serabut-nerve fibers spread
throughout this area of the brain and secrete norepinephrine
pervasive stimulates the brain to increase activity. Norepinephrine
is found high in the sympathetic nerve. Its function is regulating
the function of alertness, focus and orientation; set the "Fight-
Flight" as well as learning and memory.
2) Substantia nigra and dopamine system (DA)
This area is adjacent to the anterior superior mesensefalon and
neurons transmit nerve endings mainly to the caudate nucleus and
putamen cerebrum, this is the place that secrete dopamine. Also
adjacent neurons that secrete dopamine, but her nerve endings all
over the ventral area of the brain primarily to the hypothalamus
and the limbic system. Its function is regulating the function of the
mind, take decisions, reward-seeking behavior and play a role in
integrating kignisi.
3) Rafe nuclei and system serotonin (5-HT)
Located d the central part of the pons and medulla, Most of these
nuclei neurons secrete serotonin. Functions such as penganturan in
sleep, pain perception, mood status and regulate body temperature
as well as play a role in aggresi or angry behavior and libido.
4) Gigantoselular reticular neurons excitatory area and system of
acetylcholine (ACh). Is a neurotransmitter that is not produced
within neurons and transported throughout the brain. Have high
concentrations in the basal ganglia and motor cortex. Functioning
as attention, memory, thirst, setting the mood, REM sleep, sexual
behavior and muscle tone

13
5) glutamate
Is the major excitatory neurotransmitter in the brain in which
nearly every acre glutamate.Glutamate brain contains a high
concentration in corticostrial and in cerebellar cells. Disturbances
in this neurotransmitter will result in an effective bipolar disorder
or disease and epilepsy. The main function of glutamate is setting
memory capability and maintain both gungsi automatically.
6) GABA (Gamma Amino Acid Butytric)
Is a neurotransmitter that plays an important role in the symptoms
of mental disorders. Virtually every area of the brain contain
GABA neurons. Many pathways in the brain uses the
neurotransmitter GABA and are the main to Purkinje cells. GBA
moved from sninaps through catabolism by GABA transminase. Its
function is meurunkan arousal (activation condition of various
organs which occur in a person affected by psychological and
physiological state) and reduce aggression, anxiety and active in
excitation functions.

PHYSIOLOGICAL SYSTEMS LIMBIC

Posterior hypothalamic

a) Dorsomedial nucleus regulate gastrointestinal stimulation

b) Perifornikal nucleus regulates hunger, blood pressure and
feeling angry and rampage
c) Ventromedial nucleus regulate satiety and neuroendocrine
d) Arkuatus nucleus and periventricular zone set neuroendocrine
e) Agency reflex mammilary set meal
f) Lateral hypothalamic area regulate hunger and thirst

The anterior hypothalamus

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 a) Paraventricular nucleus regulates the release of oxytocin and
water storage
b) The medial preoptic area regulate bladder contractions,
decreased heart rate and blood pressure
c) Hypothalamic preoptic area of the posterior and anterior
regulate body temperature regulation, panting, sweating and
inhibiting thyrotropin
d) Supraoptikus nucleus regulates the release of vasopressin

Hippocampus

a) An additional channel through which the incoming sensory

signals, which can start with a behavioral reaction
berbeda.Seperti purpose as in other limbic structures,
stimulation of various areas within the hippocampus almost
always can lead to one of the various behaviors

b) Memory settings occur in the hippocampus

Limbic cortex function

a) Part of the limbic system of the least understood is the ring of

the cerebral cortex, called the limbic cortex, which surrounds
the subcortical limbic structures. This cortical functioning as a
transitional zone which d skip signal dijalarkan of the rest of the
cerebral cortex in the limbic system and also in the opposite
direction. So it becomes a cerebral association area to regulate
behavior

b. What is the relation between age and gender with this case?
Prevalence of schizophrenia for man and woman is equivalent. But
onset earlier happen to man. Peak age of onset in man is 8 until 25

15
 years old and in this case Mr. is 30 years old, same like the theory
(Kaplan and Sadock, 2010).

c. What is the meaning Nassar disturbing neighborhood since one month

ago?

Premorbid indicators (pre-illness) pre-schizophrenia among others

1) inability to express emotions: cold face, rarely smiling,
indifferent.
2) Deviations of communication: the patient is difficult talks
focused, sometimes distorted or spinning.
3) Impaired attention:: the patient is not able to focus, sustain, or
shift attention.
4) Nuisance behavior: being shy, introverted, withdrawn socially,
can not enjoy a sense of fun, challenging no apparent reason,
disruptive and undisciplined.

2. According to his mother, approximately 8 month ago, right after Nassar

cancelled marriage, the patient started to daydreaming and withdrawing
from society. The patient starting to indolently going out and talking less
with his family.
a. What is the meaning according to his mother, approximately 8 month
ago, right after Nassar cancelled marriage, the patient started to
daydreaming and withdrawing from society?
the meaning according to his mother, approximately 8 month ago, right
after Nassar cancelled marriage may become psychosocial stressor that
caused Mr. R’s complain. the patient started to daydreaming and
withdrawing from society signifies the prodromal phase of
schizophrenia.

16
 b. what is the meaning the patient starting to indolently going out and
talking less with his family?
The meaning is that Mr Nassar started to have auditoric hallucinations,
which might makes him go out idolently and talk less with his family

c. what are the relation between of stressor of chief complaint?

it is mean the cancelled marriage is a stressor or traumatic
psychosocial that can caused Nassar was suffering depression. In this
can the depression was not having a right treated, that’s make the
depression was getting worse and can caused the symptom of
schizophrenia begin to appear.

3. Six month ago, the patient starting to shows a change of personality. The
patient believe that the neighbors were mocking him behind his back. The
patient also didn’t want to go the local market because he believes that the
seller also mocking him. Nassar started to eat less, seldomly takes bath,
and his daily activity was watching television.
a. What os the meaning six month ago, the patient starting to shows a
change of personality?
the meaning is nassar has personality disorder (axis 2).

b. what is the classification of personality disorder?

1. F60.0 Paranoid Personality Disorders
Diagnostic Guidelines Personality disorders with characteristics:
a) Excessive sensitivity to failure and rejection
b) The tendency to keep holding grudges, for example Stabit
refuses to forgive an insult and hurt or a small problem
c) Deep suspicion and tendency to distort experience by
misinterpreting neutral or friendly actions of others as hostility
or humiliation

17
 d) Feeling hostile and insistent about personal rights u regardless
of the situation (actual situation)
e) Recurring suspicion, without justification (justification), about
sexual loyalty from their partners
f) he tendency to feel himself excessively important, which
manifests in attitudes that always refer to themselves (self-
referential attitude)
g) Preoccupation with schemed and non-substantive explanations
of an event, both concerning the patient itself and the world at
large. For diagnosis, it needs at least 3 of the above.

2. F60.1 Schizoid Personality Disorder

Diagnostic Guidelines for personality disorders that meet the

following description:

a) Few (if any) pleasurable activities.

b) Cold emotions, horizontal or uncaring affect (detachment)
c) Lack of ability to express warmth, tenderness or anger towards
other.
d) There is apparent disregard for both praise and criticism
e) Less interested in experiencing sexual experiences with others
(taking into account the age of the patient)
f) Almost always choose activities that are done alone
g) Preoccupation with fantasy and excessive introspection
h) Do not have close friends or close personal relationships (if
there is only one) and no desire to establish such a relationship
is very insensitive to the prevailing social norms and habits.

For diagnosis, you need at least 3 of the above

3. F60.1 Schizoid Personality Disorder

18
 Diagnostic Guidelines for personality disorders that meet the
following description:

a) Few (if any) pleasurable activities.

b) Cold emotions, horizontal or uncaring affect (detachment)
c) Lack of ability to express warmth, tenderness or anger towards
others
d) There is apparent disregard for both praise and criticism
e) Less interested in experiencing sexual experiences with others
(taking into account the age of the patient)
f) Almost always choose activities that are done alone
g) Preoccupation with fantasy and excessive introspection
h) Do not have close friends or close personal relationships (if
there is only one) and no desire to establish such a relationship
is very insensitive to prevailing social norms and habits.

For diagnosis, you need at least 3 of the above

4. F60.2 Dissocial Personality Disorders

This personality disorder is usually a concern due to the large

differences between the behavior and prevailing social norms, and
is characterized by:

a) Being indifferent to the feelings of others

b) An attitude that is very irresponsible and hydrational is
continuous (persistent), and does not care about social norms,
regulations and obligations.
c) Not being able to maintain a relationship for a long time, even
though there is no difficulty in developing it
d) Tolerance to frustration is very low and the threshold is low to
vent aggression, including acts of violence

19
 e) Not being able to experience guilt and benefit from experience,
especially from punishment
f) Very likely to blame others, or offer reasonable rationalization,
for behaviors that cause patients to conflict with the
community.

For diagnosis, it needs at least 3 of the above.

5. F60.3 Unstable Emotional Personality Disorders

There is a striking tendency to act impulsively without considering

the consequences. along with emotional instability; Two typical
variants are related to impulsivity and lack of self-control.

6. F60.4 Histrionic Personality Disorders

a) Expression of emotions that are made up (self-dramatization),

theatrical (theatricality), which is exaggerated (exaggerated)
b) Are suggestive, easily influenced by others or by
circumstances
c) A shallow and unstable affective state
d) Continually looking for excitement, appreciation from others,
and activities where the patient is the center of attention
e) Inadequate or seductive appearance or behavior
f) Too concerned with physical attractiveness

For diagnosis, it needs at least 3 of the above.

7. F60.5 Anankastic Personality Disorders

a) Excessive feelings of doubt and caution

b) Preoccupation with details (details), rules, list, order,
organization or schedule

20
 c) Perfectionism that influences task completion;
d) Excessive research, over-caution, and undue attachment to
productivity to the point of ignoring satisfaction and
interpersonal relationships
e) Excessive attachment and attachment to social habits
f) Stiff and stubborn
g) Unreasonable coercion so that other people follow exactly how
to do things, or unreasonable reluctance to allow others to do
something
h) Mixing thoughts or compulsive and reluctant encouragement.

For diagnosis, it needs at least 3 of the above.

8. F60.6 Anxiety (Avoiding) Personality Disorders

a) Feelings of tension and fear that are persistent and pervasive

b) Feeling he is incapable, unattractive or inferior to others
c) Excessive preoccupation with criticism and rejection in social
situations
d) Reluctance to engage with people unless you feel confident that
you will be liked
e) Restrictions in lifestyle due to physical security reasons
f) Avoiding social or work activities that involve a lot of
interpersonal contact for fear of being criticized, not supported
or rejected.

For diagnosis, it needs at least 3 of the above.

9. F60.7 Dependent Personality Disorders Diagnostic Guidelines

Personality disorder with characteristics:
a) Encourage or allow others to make the most important
decisions for themselves

21
 b) Putting one's own needs lower than others on whom he is
dependent, and undue compliance with their desires
c) Unwillingness to make reasonable requests to people where
they depend
d) Feeling bad or helpless when alone, because of exaggerated
fears about the inability to take care of themselves
e) Preoccupation with fear will be left by those close to him, and
left to take care of himself
f) Limited ability to make daily decisions without excessive
advice and support from others.
For diagnosis, it needs at least 3 of the above (Maslim, 2013).

Personality disorders are inflexible and maladaptive personality traits

that cause significant dysfunction or subjective suffering.
Distribution of personality disorders by group:
1. Group A: schizotipal personality disorder, paranoid personality
disorder and schizoid personality disorder
2. Group B: antisocial personality disorder, borderline personality
disorder, narcissistic personality disorder and histrionic personality
disorder.
3. Group C: avoidance personality disorder, obsessive-compulsive
personality disorder and dependent personality disorder.

c. what is the meaning the patient believe that neighbors were mocking
him behind his back and also didn’t want to go the local market
because he believes that the seller also mocking him?
its mean Nassar was having Paranoid Schizophrenia.
Synthesis :
Paranoid schizophrenia must have auditory hallucination, persecutory
delusion and reference delusion

22
d. what is the classification of hallucination?
Type of Hallucination

1. Hypnagogic hallucinations, false perceptions that occur when

falling asleep.
2. Hypnopompic hallucinations, false perceptions that occur when
you wake up.
3. Auditory hallucinations, false perceptions will sound.
4. Visual hallucinations, false perceptions involving vision.
5. Olfactic hallucinations, false perception will smell.
6. Gustatoric hallucinations, false perceptions of taste.
7. Tactile hallucinations, false perceptions of touch or surface
sensation.
8. Somatic hallucinations, false sensation of something being
shown to his body.
9. Hallucinations liliput, false perception that the size of the object
looks smaller.
10. Congruent-mood hallucinations, hallucinations whose contents
are consistent with depressive mood or manic.
11. Hallucinations that are not congruent-mood, hallucinations
whose contents are not consistent with depressive mood or
manic.
12. Hallucinosis, hallucinations due to chronic alcohol abuse and
occur in clear awareness. The most frequent audit.
13. Synesthesia, hallucinations caused by other sensations.
14. Trailing phenomenon, abnormalities of perception related to
hallucinogenic drugs in the form of moving objects can be seen
as a series of separate images.
15. Hallucinations of command, false perceptions of commands
that make a person feel obliged to obey or not refuse
(Dharmono, 2017).

23
e. what is the meaning nassar started to eat less, seldomly takes bath, and
his daily activity was watching television?
The meaning Nassar started to eat less, seldomly takes bath and his
daily activity was watching television is a negative symptom of
schizophrenia in the form of avolition and asociality.

f. how the pathophysiology of hallucination in this case?

Mesolimbic way control emotion of happiness.In schizophrenia
dopamine more active at mesolimbic way.Vential tegmental area to
nucleus acumbens through amygdala and hypocampus. In hypocampus
dopamine at presinaps get out from vesicle, through canal and
penetrate to post sinaps. After that, dopamine occupy in D2 receptors.
But there is something wrong in the receptors. In hypothesis it maybe
cause by dopamine realease more higher, dopamine receptors higher,
hypersensitivity of dopamine receptors or combination from the third
causes. All of that makes a sign and symtopms like hallucination and
delution.

g. What are the physycotic disorder?

Psychotic Disorders is a mental disorder characterized by the inability

of individuals assess the fact that occur, for example, there are
hallucinations, delusions or disorganized or bizarre behavior.
Classification of Psychotic Disorders:
1. Schizophrenia and other psychotic disorders
a) Schizophrenia
b) Disorders Skizotipal
c) Supposition interference Residential
d) Acute Psychotic Disorders and Temporary
e) Induction Supposition Disorders

24
 f) schizoaffective disorder
g) Psychotic Disorders Non-Organics
2. Disorders Atmosphere Feelings (Affective Mood)
a) Manic episode
b) Bipolar Affective Disorders
c) episode Depression
d) Recurrent Depressive Disorders
e) Feelings Residential interference Atmosphere
- Skilotimia
- dysthymia
f) Other Feelings interference Atmosphere
Residual category for disorders atmosphere settled feeling that
is not severe enough or lasted long enough to meet the criteria
skilotimia and dysthymia (Maslim, 2013).

4. On the previous month, the patient won’t go out from his home, because
he believes that the neighbors are plotting to harm him. Every time there
was someone who passes through his home, he always throws some stone
and shouts “Don’t disturb me! Go away!”. The patient also threatens his
father with machete, because he believes that his father was trying to kill
him. He seldomly sleep sleep, and everynight he always patroliing around
the house to check whether there was someone who wants to harm him.
The patient didn’t want to take care of himself, and only eats when being
told.
a. What is the meaning, on the previous month, the patient won’t go out
from his home, because he believes that believes that the neighbors
are plotting to harm him?
the meaning, on the previous month, the patient won’t go out from his
home, because he believes that believes that the neighbors are plotting
to harm him is persecutory delusion and reference delusion.

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b. what is the meaning everytime there was someone who passed
through his home, he always throws some stone and shouts “Don’t
disturbe me! Go away!”?
the meaning is Nassar has auditory hallucinasion.

c. what is the meaning the patient also threatens his father with machete,
because he believes that his father was trying to kill him?
its mean Nassar was having Paranoid Schizophrenia.
Synthesis :
Paranoid schizophrenia must have auditory hallucination and
persecutory delusion.

d. what is the meaning he seldomly sleep, and everynight he always

patroling around the house to check whether there was someone who
wants to harm him?
the meaning is Nassar has persecutory delusion.

e. what is the classification of dellusion?

1) Bizzare delusion is false, impossible and strange beliefs
2) Systematic delusion is false beliefs or beliefs that are combined
with a theme / event that can be followed
3) Nihilistic delusion is a mistaken feeling that he and his
environment or the world doesn’t exist or are doomed
4) Somatic delusion is erroneous beliefs involving bodily functions
5) Paranoid delusion
a) Greatness delusion is the belief that he is a person who is very
strong, very powerful or very big
b) Chase delusion is thought that he was a victim of an attempt to
hurt him
c) Referral delusion is the belief that the behavior of others will
surely slander, endanger, or will harm him

26
 d) Controlled delusion is the belief that his desires, thoughts, or
feelings are controlled by outside strength
 Thought withdrawal is the delusion that his mind is drawn
by other people or other p
 Thought insertion is the delusion that his mind is
intercepted by other people or other strength
 Thought broadcasting is the delusion that his mind could
be known to others, spread in the air
 Thought control is the delusion that his mind is controlled
by other people or other strength
(Dharmono, 2017)

f. what are the classification of sleep disorder?

Sleep disorders are divided into 3 types namely
1) Insomnia: difficulty starting or maintaining sleep.
Insomnia is divided into 3 types, namely:
a) Initial insomnia, which is difficulty in starting sleep.
b) Intermittent insomnia, which is the inability to keep sleeping
because it often awakens.
c) Terminal insomnia, which is to wake up early but it is difficult
to fall asleep again.
2) Hypersomnia: excessive sleep, drowsiness (somnolence) during
excessive daytime, or both.
3) Parasomnia: an undesirable phenomenon that occurs suddenly
during sleep (Kaplan & Sadock, 2010).

g. what is the meaning the patient didn’t want to take care of himself
and only eats when being told?
he has negative symptoms in the form of avolition. Avolition is
reducing the desire to do proposeful activities

27
5. Before this complaint, Nassar was known as a smart student in school, and
tend to be perfectionist. Nassar used to be a civil servant, but he didn’t
went to work since two month ago because of his fear of going out. Nassar
was the only child and came from a middle-class family.
a. What is the meaning before this complaint, Nassar was known as a
smart student in school, and tend to be perfectionist?
The meaning before this complaint, Nassar was known as a smart
student in school and tend to be perfectionist is melancholy personality
(anascastic)

b. what is the meaning Nassar used to be a civil servant, but he didn’t

went to work since two month ago because of his fear of going out?
The meaning is Nassar suffering lack of social functioning.

c. what is the meaning Nassar was the only child and came from a
middle-class family?
Nassar is the only child means that the whole attention of the family
directed at him,and that attention comes from his Authoritarian mother
and Permissive Father,which leads into the personality he had now
(perfectionist)

d. what is the relation between his personality with chief complaint?

Anankastic personality disorder has the characteristics of a limited
emotional, order, doubt and plan everything perfectly, so that if the
plans are not met can cause depression and can become schizophrenic

6. Nassar was known to had a causin who suffers the same symptom and was
hospitalized because of it.
a. what is the meaning Nassar was known to had a causin who suffers the
same symptom and was hospitalized because of it?

28
 The meaning is Mr. Nassar is having genetic predisposition of
schizophrenia.

b. what are the risk factor of schizophrenia?

1. Genetic factor
Sibling : 7-15 %
Stepbrother or Stepsister : 0,9 – 1,8 %
One of parent : 7-16 %
Heterozygous twins : 2-15 %
Monozygous twins : 61-86 %
2. Biochemistry factor
Hyperactivity of Dopamine or abnormal sensitivity of
neurotransmitter
3. Psychosocial factor
Psycho traumatic
Pathological parent and child relationship (Padma, 2017)

c. what are the classification of schizophrenia?

1) F20.0 paranoid schizophrenia
a) Temperature schizophrenia general criteria
b) Hallucinations and / or delusions must be prominent
c) Affective disorders, will impulses and conversation as well as
catatonic differences are relatively unrealistic and prominent.
2) F20.1 hebefrenic schizophrenia
Meet the general criteria of schizophrenia
Diagnosis of heberphrenia for the first time is only diagnosed in
adolescents or young adults (15-25 years)
a) Premorbid personality
b) Further monitoring is required for 2-3 months
c) Affective disorders and will impulses, as well as thought
processes are considered prominent.

29
3) F20.3 catatonic schizophrenia
Meet the general criteria of schizophrenia
a) One or more of the features: stupor, anxiety, displaying certain
body positions, negativism, rigidity, accessing cerea,
automstism commands
b) In patients who are not related to the manifestations of
catatonic, schizophrenic diagnosis may have to be postponed
until there is evidence of a possible difference.
4) F20.4 unspecified schizophrenia (not differentiated)
a) Meet the general criteria of schizophrenia
b) Does not meet criteria for paranoid, heberferenic or catatonic
schizophrenia
c) Does not meet criteria for residual schizophrenia or post-
sciozophrenic depression
5) F20.5 Post-schizophrenic depression
Diagnosis is made when
a) Patients suffering from schizophrenia (who meet the general
criteria for schizophrenia) during the last 12 months
b) Some schizophrenia symptoms still exist
c) Depressive symptoms stand out and get the least approval for
depressive episodes (F32.-) and exist within a period of at least
2 weeks
d) If the patient does not show symptoms of schizophrenia, the
diagnosis becomes a depressive episode (F32.-)
6) F20.6 residual schizophrenia
Use an approved diagnosis, all of these requirements must be
agreed to:
a) Symptoms of "negative" from schizophreia are prominent
b) There have been few episodes of one clear psychotic episode in
the past that meet the criteria for the diagnosis of schizophrenia
c) At least more than 1 year

30
 d) No dementia or other organic disorders
7) F20.7 schizophrenia simplex
The diagnosis of schizophrenia simplex is difficult to make
depending on the stabilization of the slow and progressive
development of:
a) "Negative" symptoms typical of residual schizophrenia:
Accompanying changes in desired personal habits, loss of
interest, purpose in life, and self desires from the social
b) This disorder is less clear than other psychotic sub-types of
schizophrenia.
8) F20.8 other schizophrenia
9) F20.9 schizophrenia which is not classified (Maslim, 2013).

d. what are the stages of skizoprenia?

1) Prodomal Phase
- Lasts 6 months - 1 year
- Disturbances can be in the form of self care, disturbances in
academics, disruptions in work, disruption of social functioning,
disturbance of mind and perception
2) Active phase
- Lasts 1 month
-Disorders can be in the form of psychotic symptoms;
Hallucinations, delusions, disorganization of thought processes,
speech disorders, behavioral disorders, accompanied by
neurochemical abnormalities
3) Residual Phase
Usually experience at least 2 symptoms; affect disorders and role
disorders, attacks usually recur.

7. Autoanamnesis :

31
 During the interview, the patient tends to be rowdy, anxious and not
cooperative on answering the question given. The patient tends to be angry
when being asked and tries to evict the examiner.

Premorbid history :
Baby : being fed with breast milk untill 6 month old, and continued with
formulated milk due to his mother jobs.
Chilhood and adolescence : jolly, had a lot of friend, parenting :
authoritarian mother with permissive father
Early adult : jolly with a lot of friend

Education history :
Elementary school, junior high, senior high, university : high achieving
student who always be the best ten of his class

Medical history :
There is no history of head
There is no history of NAPZA
There is no history of fever
There is no history of other medical condition
a. What are the interpretion of autoanamnesis, premorbid history,
education history and medical history?
Autoanamnesis : clinical manifestasion from positive symptomps of
schizophrenia and paranoid schizophrenia.
premorbid history : fixation on trust and mistrust phase, due to his
authoritarian and permissive parents.
education history : normal.
medicall history : eliminating diagnosis of axis 3.

8. Physical examination :

32
 Awareness : disturbed compos mentis; blood pressure 110/80 mmHG,
pulse 84 x/m, RR 20 x/m, temp 36,7° C, nutritional status BW 60 kg, BH
160 cm.
a. What are the interpretation of physical examination?
disturbed compos mentis = abnormal

9. Pryciatry status :
Appearance : medium postured patient, lack of self care, eye contact with
the interviewer are exist.
Attitude and behavior : not cooperative and agitative
Speaking : fluent verbalization
Mood : hypertimic and unstable
Affect : inappropriate
Thought : not realistic, irrelevant, incoherent, delusion (+)
Perception disorder : auditoric hallucination (+), illution (+)
Intelligence : memory is normal, there is no amnesia
Time-place orientation : normal
Reality testing ability : disturbed
Insight : first grade
Judgement : disturbed
a. What are the interpretation of psychiatry examination?
Psychiatric Status Interpretation
Appearance medium postured
patient, lack of self
care, eye contact with Function
the interviewer are disturbance
exist.
Intelligence function Good memory
No amnesia
Good orientation
Poor discriminative

33
 judgementAppropriate Negative
Level of intelligence symptoms of
No intellectual decline schizophrenia
Emotion Mood: hypertimic and
unstable
Afek: inappropriate

Thought Not realistic,

sometimes irrelevant
Incoherent Positive
Delution of control symptoms of
Perception Auditory hallucination schizophrenia
existed No illusion (delution and
hallucination)

Reality Testing Ability Distorted Can’t to divided

(RTA) which the real
Insight 1st degree condition or just
imagination

b. what are the classification of insight?

1) Insight grade 1: total denial of the disease.
2) Insight grade2: ambivalence to the disease.
3) Insight grade3 : blaming other factors for causing the disease.
4) Insight grade 4: realize he was sick and needed help but did not
understand the cause of the pain.
5) Insight grade 5: aware of the disease from the factors associated
with the disease but does not apply in practical behavior
6) Insight grade 6: fully aware of his situation with motivation to
achieve improvement (Kaplan, 2010).

34
c. how to do reality testing ability?
REALITY TESTING ABILITY

A person's ability to judge reality. This ability will determine

perceptions, responses and interactions in relationships with the
reality of life. Problems, delusions, and hallucinations are examples of
severe difficulties in interaction skills (Ability Reality Test).

VALUE POWER

1) The Power of Social Value: the ability of a person to obtain

correct approval (today) and actions that are in accordance with
these considerations taking into account the social rules that apply
in his social and cultural life. In severe me ntal disorders or
antisocial protection, social values are often disrupted.
2) Power Value Test: the ability to determine the correct place and in
accordance with a given.

SURVEILLANCE

The ability of a person to understand the true cause and meaning of

certain situations. In a broad sense, insight is often referred to as self-
insight, that is one's understanding of one's own conditions and
speech in the context of cross reality. In the narrow sense is the
patient's understanding of the disease.

Types of views:

1. First degree surveillance: total denial of the disease

2. Second degree surveillance: ambivalence towards the disease

3. Third degree surveillance: assure other factors as the cause of the

disease

35
 4. Fourth degree surveillance: need sick help and need help but not
Successfully overcoming the illness

5. Level 5 view: aware of the disease and the factors associated with
the disease are not in accordance with its practical affairs

6. Level 6 view (healthy): can be understood as needed

10. How to diagnose?

based on PPDGJ III must have at least one symptom from 9 symptom,
and in this case there are symptom that Nassar suffer :

1. Though withdrawal.
2. Though broadcasting, in this case nassar shouts “ Don’t disturbed me!
Go away!”
3. Negative symptom (talk less and indolently going out).
4. Change of personality behavior like eat less, seldomly takes a bath
and his daily activity was just watching television.
5. All of the symptom before occur at least 1 month.
6. There is hallucination and delusion (in this case there was auditoric
hallucination, persecutory delusion that really dominant).
7. Family history that suffer the same symptom
8. From the autoanamnesis the patient tends to be rowly, anxious and
not cooperative on answering.
9. From premorbid history : parenting (authoritarian mother with
permissive father).
10. From the psychiatry status : there are negative symptom of
schizophrenia, positive symptom of schizophrenia and there was
disorder of reality testing ability (Maslim, 2013)

11. What are the differential diagnostic in this case?

1) F20.0 paranoid schizophrenia

36
 2) F20.6 simplex schizophrenia
3) F23.0 schizoaffective

12. What is the working diagnostic in this case?

Axis I : F20.0 Paranoid Schizophrenia
Axis II : F60.5 Anankastic Personality
Axis III : none
Axis IV : Traumatic psychosocial (cancelled marriage)
Axis V : GAF scale 60-51

13. How to manage the case’s procedure comprehensively?

Non pharmacology
1) Psychosocial therapy With psychosocial therapy the sufferer is
intended to be able to re-adapt to the surrounding social
environment and be able to care for themselves, be able to be
independent not dependent on others so that it does not become a
burden to the family or community, the patient is strived to not be
alone, not daydreaming, many activities and busyness and lots of
hanging out.
2) Psychoreligious therapy Diversity therapy for schizophrenics turns
out to have benefits for example, clinical symptoms of
schizophrenic psychiatric disorders disappear faster. Religious
therapy is meant in the form of religious ritual activities such as
prayer, prayer, praying praise to God, religious lectures and study
of the scriptures.
3) Physical therapy in the form of exercise.
4) Various activities such as courses or tutoring (Maramis, 2009)
Phamacology
Antipsychotics or also known as neuroleptics (major tranquilizer) are
useful in the treatment of acute and chronic psychosis. Antipsychotics
work by occupying dopamine receptors, serotonin and several other

37
 neurotransmitter receptors. Antipsychotics are distinguished from typical
antipsychotics (first generation antipsychotics) including chlorpromazine,
flufenazine, thioridazine, haloperidol; and atypical antipsychotics (second
generation antipsychotics) such as clozapine, olanzapine, risperidone and
others.
APG-I is useful for treating positive symptoms while negative symptoms
are almost useless. schizophrenia should be treated with APG-II because it
is beneficial for positive and negative symptoms. APG-II drug that is often
used is risperidone. the most commonly used dose of risperidone is 2-8 mg
day, with a maximum dose of 16 mg.
Pharmacokinetics of risperidone :
Risperidone is metabolized in the liver to 9-hydroxirisperidone, whose
pharmacological profile is the same as its parent components. The peak
plasma level of the parent component is reached after 1 hour of
administration. While for the metabolite results after 3
hours. Risperidone's bioavailability is 70%. the liver enzyme whose
metabolism is CYP 2D6. This enzyme is not active in about 7% of white
people. Because their metabolites have almost the same activities as their
parent components, this variation has little effect
Pharmacodynamic of risperidone :
Risperidone is a strong antagonist to both serotonin and D2 receptors.
Risperidone also has a strong affinity for Alfa 1 and Alfa 2 but its affinity
for beta receptors and muscarinics is low. although it is said to be a strong
D2 antagonist, its strength is much lower when compared to haloperidol.
As a result, the extrapyramidal side effects are lower when compared with
haloperidol. Activity against negative symptoms is associated with activity
against 5 HT 2 which is also high (Amir, 2017)

14. What are the complication in this case?

1) Social function reduction
2) Cognitive function reduction

38
 3) Death (suicide attempted)

15. How is the prognostic in this case?

Vitam : dubia ad bonam
Fungsionam : dubia ad bonam
Sanationam : dubia ad bonam

16. What is the general practitioner’s competence in this case

3A (not an emergency)

17. What is islamic view in this case?

Q.S An-Nisaa : 63
They are people who God knows what is in their hearts. Therefore you
turn away from them, and teach them a lesson, and tell them the words
which are on their souls (Q.S An-Nisaa : 63)
"Women are not good for bad men, and bad men are for bad women. Good
women for good men and good men for good women. (Qs. An Nur:26)

39
2.6 Conclusion

Nassar, a 30 years old suffering auditoric hallucinasion, persecutory

delusion, reference delusion, and lack of social functioning due to Paranoid
Schizophrenia et causa traumatic psychosocial.

2.7 Conceptual framework

Risk factors : Stressor : traumatics

Age, Gender, event (Cancelled
genetic marriage)

Paranoid Schizophrenia

Auditory Persecutory Lack of social

hallucinasion delusion and functioning
reference deluson

40
 BIBLIOGRAPHY

Amir, N. 2013. Skizoprenia dalam Buku ajar psikiatri. Edisi ke-3. Jakarta: Badan
Penerbit Fakultas Kedokteran Universitas Indonesia

Boeree, George. 2013. General Psychology. Jogjakarta. Prismasophie

Dharmono, S. 2017. Tanda dan Gejala Klinis Psikiatrik dalam Buku Ajar
Psikiatri. Edisi ketiga. Jakarta : Badan Penerbit FK UI

Hapsari, Indri, et al. 2014. Physiology Psychology. Bandung : PT Youth

Rosdakarya
Kalat, James W. 2008. Biopsychology. Jakarta : Salemba Humanika
Kaplan, HI, Sadock, BJ & Grabb, JA., 2010. Kaplan-Sadock Sinopsis Psikiatri
Ilmu Pengetahuan Prilaku Psikiatri Klinis. Tanggerang : Bina Rupa Aksara

Maslim R. 2013. Buku Saku Diagnosis Gangguan Jiwa. Jakarta: FK Unika

Maramis WF. 2009. Catatan ilmu kedokteran jiwa. Surabaya: Airlangga

University Press.

Padma, Sri. 2017. Perawatan pada pasien Skizofrenia berdasarkan subunit

Skizofrenia. Malang : Fakultas Kedokteran Univesitas Diponegoro.

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