SCENARIO B BLOCK XIV

Group 6
Derry Nuansa Ilham (702017021)
Fajar Al-Farabi (702017031)
Melisa Nopa Belia (702017014)
Muhammad Ichsan Pradipta (702017063)
Thesa Lonica (702015002)
Yosi Anggraini (702017007)
Meri Oktarina (702017084)
Vera Novita Sari (702017065)
Septi Fadhillah Sarabayan P (702017053)
Meysa Rosalina Agda (702017022)
 • Case scenario
• “Stop Mocking Me”
• Nassar, a 30 years old brought to the emergency department due to disturbing the neighborhood since one
month age. According to his mother, approximately 8 month age, right after Nassar cancelled marriage, the patient
started to daydreaming and withdrawing from the society. The patient starting to indolently going out and talking less
with family.
• Six month ago, the patient starting to shows a change of personality. The patient believe that the neighbor were
mocking him behind his back. He patient also didn’t want to go the local marcet because hi 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 neighbor are plotting to
harm his. Every time there was someone who passes through his home, he always throws some stone and shouts
“don’t distrub 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, and everything he always patrolling around the house to check wether there
was someone who wants to harm his. The patient did’t want to take care of him self, 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 servent, 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
• During the interview, the patient tend to be rowdy, anxious and not cooperative on answering the question given. The
patient tendt to be angry when being asked aan tries to evict the examiner.
• Premorbid History :
• Baby : being fed with breast milk untul 6 month old, and continued with formulated milk due to his mother jobs
• Chilhood and adolescence : jolly, had a lot of friends, parenting : authoritarian mother with permissive father.
• Early adult : jolly with a lot of friend.
• Education History :
• Elemtary 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 Exammination :
Awareness : disturbed compos mentis ; blood pressure 110/80 mmHg, pulse
84x/m, RR 20x/menit, Temp 36.7 C, nutritional status BW 60 kg, BH 160 cm.
Phychiatry Status :
Appearance : medium postured patient, lack of self care, eye contact with the
interviewer are exist.
Attitude and behaviour : not cooperative and agitative
Speaking : fluent verbalization
Mood : Hypertimic and unstable
Affect : inappropriate
Thought : not realistic, irrelevant, inchoherent. Delusion (+)
Perception dissorder : auditoric hallucination (+), illution (-)
Intelligence : memory is normal, theres no amnesia
Time-place orientation : normal
Reality testing ability : disturbed
Insight : first grade
Judgement : distrubed
Clarification of term
Halucination Sensory perception (vision, touch of hearing, sight or
sight) without external stimulation

Delusion When the people fell his/her midloss control by

something or someone

Illution A mental impression derivade from miss interpretation of

an actual exprerience

Amnesia Patological memory disorder

Mood Way to expressing someone felling and emotions

Affect External expretion of emotion that are bound to an

adjective
 Reality testing Physotherapeutic function by which of the object or
ability real world

Perfectionist People who wanted everything to be perfect

Daydreaming Condition when someone mind breaks with the environment,

where one’s contack become blurred and partially replaced by
visual

Incoherent Thought that are generally incomprehensible, thought or

words that come out without logical connection

Hypertimik Exceessive emotional lism

Problem analysis
1. Nassar, a 30 years old brought to the emergency department
due to disturbing the neighborhood since one month age.
According to his mother, approximately 8 month age, right
after Nassar cancelled marriage, the patient started to
daydreaming and withdrawing from the society. The patient
starting to indolently going out and talking less with family.
A. What are the neuroanatomic and neurotransmitter in the
case?
Answer :
• Neuroanatomic
Hypothalamus
• The hypothalamus plays many roles in maintaining
homeostasis. However, its role in the limbic system receives
less attention.
Hypocampus
• The hippocampus is an allocortical structure that is important
for the consolidation of information, including short-term,
long-term and spatial memory.
Amygdala
• The amygdala is a subcortical structure of the limbic system,
located in the medial temporal lobe, whose role involves
processing emotional responses- specifically fear, anxiety, and
aggression.
Neurotransmitter
• Norepinefrin
• Serotonin
• Dopamine
b. What is the meaning nassar disturbing the neighborhood since one
month ago?
Answer :
Indicates hyperactive behavior due to increased dopamine
neurotransmitter in nigrostriatal which is a regulator of body
movements.

c. What is the meaning nassar started to daydreaming and withdrawing

right after the cancelled marriage ?
Answer :
• The meaning of nassar started to day dreaming and withdrawing
right after the canceled marriage is one of the negative symptoms of
schizophrenia.
d. What is negative symptoms in schizophrenia ?
• Answer :
• Negative symptoms that are shown in schizophrenics:
1. afect
2. Isolate self (Withdrawl)
3. Emotional contact “poor”
4. unhedonia
e. What is the mental defance mechanism ?
• Answer : Sigmund Freud (1894, 1896) noted a number of ego defenses
which he refers to throughout his written works
1. Mental defence mechanism level 1 :
• Denial
• Distortion
• Projeksion
• Projective
• Splitting.
2. Mental defence mechanism level 2
• Fantasy - regression
• Projeksion - introjection
• Hipokondriasis - somatisasi
• Passive aggression
• Acting out
• Idealisation
• identifaction
3. Mental defence mechanism level 3
• Displacement
• Isolation
In the case he experiences mental defense level 2 and 3. Patient
started to day dreaming and withdrawing from the society.
f. What the relation gender and age in this case?
Answer :
• Schizophrenia is mostly experienced by men than women.
With a peak onset of 8 to 25 years for men and 25 to 35 years
for women

g. What is the mechanism of chief complain in the case ?

Answer :
• In mesocortical way, dopamine → vential tegmental area →
prefrontal cortex. Headed limbic system → less active →
disturbance of dopaminergic → decrease of dopamine →
negative symtopms (flat affect, alogia, self uncare, less
motivation, etc)
2. Six month ago, the patient starting to shows a change of
personality. The patient believe that the neighbor were mocking
him behind his back. He patient also didn’t want to go the local
marcet because hi believes that the seller also mocking him.
Nassar started to eat less, seldomly takes bath, and his daily
activity was watching television.

A. What is the meaning six month ago Six month ago, the patient
starting to shows a change of personality. The patient believe that
the neighbor were mocking him behind his back. He patient also
didn’t want to go the local marcet because he believes that the
seller also mocking him ?
Answer: The meaning is he experienced paranoid delusions, type of
pursuit. Pursuit delutions, namely the belief that he will be hurt,
harmed, harassed, or discussed by someone, organization or other
group

B. What is the classification of delusion ?

• Answer :
• Understanding is that false beliefs are based on wrong conclusions
about external reality, are inconsistent with the patient's
intelligence and cultural background, and cannot be corrected by
reasoning
Classification of Delusional :
• Bizar delusion
• Systematic delusion
• Congruent-mood delusions
• Nihilistic delusion
• Poverty delusion
• Somatic delusion
• Paranoid delusions
• Controlled delusion
• Thought withdrawn
• Thought insertion
• Thought broadcasting
• Thought control
• Jealousy delusion
• Erotomania
•  
c. What the meaning Nassar started to eat less, seldomly takes
bath, and his daily activity was watching television ?
• Answer :
There will be Avoliton in Scizophrenic patient mean he didn’t
want to take care of himself.
d. What is the relation between his problem six month ago with chief
complain ?
• Answer :
Relation between 6 month ago with chief complain is a prodromal phase of
skizofrenia which feature of the phase is explained in.
It provides an operationalized criteria of nine symptoms for schizophrenic
prodrome:
• Marked social isolation or withdrawal
• Marked impairment in role functioning
• Markedly peculiar behavior
• Marked impairment in personal hygiene and grooming
• Blunted or inappropriate affect
• Digressive, vague, overelaborate or circumstantial speech, or poverty of
speech, or poverty of content of speech
• Odd beliefs or magical thinking
• Unusual perceptual experiences
• Marked lack of initiative, interests, or energy.
e. How to mechanism additional complain ?
Answer:
Social factor (cancel merried)> disturbance in the hypothalamus>
stimulate HPA axis (CRH)> stimulate anterior pituitary (ACTH)>
stimulate adrenal cortex> excrete cortisol> neurotransmitter
imbalance> dopamine increases in mesolimbic (symptomatic (+)
auditory hallucinations and delusions in the cortex) ) and dopamine
decrease in mesocortical (unhedonia (-) symptoms, and withdrawal)
f. What is the possibility disease with chief complain ?
Answer :
• Skizofrenia
• Skizoafektif

3. On the previous month, the patient won’t go out from his home,
because he believes that the neighbor are plotting to harm him. Every time
there was someone who passes through his home, he always throws some
stone and shouts “don’t distrub 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, and everything he always patrolling around the
house to check wether there was someone who wants to harm his. The
patient did’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 the neighbor are
plotting to harm him ?
• Answer :
• The meaning is he experienced paranoid delusions.

b. What is he meaning Every time there was someone who

passes through his home, he always throws some stone and
shouts “don’t distrub me! Go away!”?
• Answer :
• The meaning is hyperactive behavior due to paranoid
delusions.
c. What in the mechanism of his complaint ?
Answer:
Social factor (cancel merried) and psychology factor (anankastik
personality) > disturbance in the hypothalamus> stimulate HPA
axis (CRH)> stimulate anterior pituitary (ACTH)> stimulate adrenal
cortex> excrete cortisol> neurotransmitter imbalance> dopamine
increases in mesolimbic (symptomatic (+) auditory hallucinations
and delusions in the cortex) ) and dopamine decrease in
mesocortical (unhedonia (-) symptoms, and withdrawal, Timid
and reserve, not to go to the collage, often spent his time
watching the television,
d. What is the meaning the patient also threatens his father with
machete, because he believes that his father was trying to kill him ?
• Answer :
The meaning is that nassar is having a paranoid delution.

e. What is the meaning He seldomly sleep, and everything he

always patrolling around the house to check wether there was
someone who wants to harm his ?
• Answer :
The meaning is that he has the characteristics of anankastic
personality. Where in anankastic personality has the characteristics
of accuracy, too careful, and undue attachment to productivity to
ignore satisfaction and interpersonal relationships.
f. What is the meaning the patient did’t want to take care of himself, and only
eats when being told ?
• Answer :
The meaning is a decrease in self-care function, which is a characteristic of
schizophrenia.

g.how is mechanism of his complaint ?

• answer:
• Social factor (cancel merried) and psychology factor (anankastik personality) >
disturbance in the hypothalamus> stimulate HPA axis (CRH)> stimulate
anterior pituitary (ACTH)> stimulate adrenal cortex> excrete cortisol>
neurotransmitter imbalance> dopamine increases in mesolimbic (symptomatic
(+) auditory hallucinations and delusions in the cortex) ) and dopamine
decrease in mesocortical (unhedonia (-) symptoms, and withdrawal)
4. Before this complaint, Nassar was known as a smart student in
school, and tend to be perfectionist. Nassar used to be a civil
servent, 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.

a. What is the meaning before this complaint, Nassar was known

as a smart student in school, and tend to be perfectionist ?
• Answer :
Nassar has annankastic personality traits namely perfectionism
and regularity.
b. What is the classification of personality disorder?
• Answer :
Classification of personality disorder (Sadock, 2014) :
1. Paranoid Personality Disorder
2. Schizoid Personality Disorder
3. Schizotypal Personality Disorder
4. Antisocial personality disorder (ASPD or APD)
5. Dependent personality disorder (DPD)
6. Obsessive conpulsive personality disorder

c. What is the meaning nassar used to be a civil servent, but he didn’t went
to work since two month ago because of his fear of going out ?
• Answer :
The meaning is self isolation occurs and is a paranoid personality trait.
d. What is the meaning nassar used to be a civil servent, but he didn’t went to work
since two month ago because of his fear of going out ?
• Answer :
The meaning is self isolation occurs and is a paranoid personality trait.

e. What is the meaning nassar was the only child and came from a middle-class family ?
• Answer :
Psychosocial factors (no sharing friends)

f. What is the meaning nassar was known to had a cousin who suffers the same
symptom and was hospitalized because of it ?
• Answer :
The meaning is predisposition factor. Most mental disorders are caused by heredity.
Where the characteristics of mental disorders that will be experienced by individuals
derived by parents and their ancestors through genes and chromosomes in
reproductive cells
5. Autoanamnesis
• During the interview, the patient tend to be rowdy, anxious and not cooperative on
answering the question given. The patient tendt to be angry when being asked aan
tries to evict the examiner.
• Premorbid History :
• Baby : being fed with breast milk untul 6 month old, and continued with
formulated milk due to his mother jobs
• Chilhood and adolescence : jolly, had a lot of friends, parenting authoritarian
mother with permissive mother.
• Early adult : jolly with a lot of friend.
• Education History :
• Elemtary 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 is the meaning during the interview, the patient tends to
be rowdy, anxious and not cooperative on answering the
question given ?
• Answer:
The meaning is motor disturbances and also shows symptoms of
paranoid schizophrenia.

b. What is the meaning the patient tends to be angry when being

asked and tries to evict the examiner ?
• Answer :
The meaning is that there has been emotion or mood irritability.
c. What is the meaning Baby : being fed with breast milk untul 6
month old, and continued with formulated milk due to his mother jobs
?
• Answer :
A recent, but small study suggests that breastfeeding in infancy may
delay the age of onset of schizophrenia.

D. What is the meaning Chilhood and adolescence : jolly, had a lot of

friends, parenting authoritarian mother with permissive father ?
• Answer :
Meaning he is jolly and had a lot friends indicates that there is no
social trauma in childhood and the meaning of his authoritarian
mother with his permissive father is hard to believe in others who
have an interruption in the oral phase (mid trush).
e. What is the meaning early adult : jolly with a lot of friend ?
• Answer :
Get rid of the diagnosis of no social trauma in childhood.

f. What is the meaning early adult : jolly with a lot of friend ?

• Answer :
Get rid of the diagnosis of no social trauma in childhood.

g. What is the meaning is There is no history of head ?

• Answer :
To rule out post traumatic stress disorder.
6. Physical Exammination :
• Awareness : disturbed compos mentis ; blood pressure 110/80 mmHg, pulse 84x/m, RR
20x/menit, Temp 36.7 C, nutritional status BW 60 kg, BH 160 cm.
• Phychiatry Status :
• Appearance : medium postured patient, lack of self care, eye contact with the interviewer are
exist.
• Attitude and behaviour : not cooperative and agitative
• Speaking : fluent verbalization
• Mood : Hypertimic and unstable
• Affect : inappropriate
• Thought : not realistic, irrelevant, inchoherent. Delusion (+)
• Perception dissorder : auditoric hallucination (+), illution (-)
• Intelligence : memory is normal, theres no amnesia
• Time-place orientation : normal
• Reality testing ability : disturbed
• Insight : first grade
• Judgement : distrubed

a. What is the interpretation of physical examination and phychiatry status ?

• Answer :
• Physical examination : normal
• Phychiatry status : schizophrenia symptoms
 Psychiatric Status Result Interpretation
Appearance Medium postured patient, lack of self care, eye contact Negative Symptom
with the interviewer are exist.

Attitude and behaviour Not cooperative and agitative Abnormal

Speaking Fluent verbalization Normal

Mood Hypertimic and unstable Abnormal, Interpretation : Mania

Affect Inappropriate Abnormal

Thought Not realistic, irrelevant, inchoherent., Delusion (+) Abnormal

Perception dissorder Auditoric hallucination (+) Abnormal : perseption disorder

Illution (-)

Intelligence Memory is normal, theres no amnesia Normal

Time-place orientation Normal Normal

Reality testing ability Disturbed Abnormal : Psychotic disorder

Insight First grade Completely denial of having illness

Judgement Distrubed Abnormal

B. How to mechanisme abnormal phychiatry status ?
Answer:
- Appearence:
Social factor (cancel merried) and psychology factor (anankastik personality)
> disturbance in the hypothalamus> stimulate HPA axis (CRH)> stimulate
anterior pituitary (ACTH)> stimulate adrenal cortex> excrete cortisol>
neurotransmitter imbalance> dopamine decreased in mesocortical > medium
postured patient, lack of self care, eye contact with the interview are exist
-Attitude and behavior:
neurotransmitter imbalance> dopamine decreased in mesocortical > not
cooperative and agitative
- mood:
neurotransmitter imbalance> dopamine increases in mesolimbic > manic
- affect:
neurotransmitter imbalance> dopamine decreased in mesocortical >
inappropriate
 - thought:
neurotransmitter imbalance> dopamine decreased in mesolimbic
> not realistic, irrelevant, incoherent. Delusion (+)
- Perception disorder:
neurotransmitter imbalance> dopamine decreased in mesolimbic
> auditoric hallucination (+)
- Reality Testing Ability
neurotransmitter imbalance> dopamine decreased in mesolimbic
> disturbed
- Judgment
- neurotransmitter imbalance> dopamine decreased in
mesocortical > disturbed
c. What is the classification of hallucination ?
• Answer :
• Classification of hallucination (Elvira, 2017).
• Hypnogogic hallucinations
• Hypnopompic hallucinations
• Auditory hallucinations
• Visual hallucinations
• Hallucination of smells
• Taste hallucinations
• Tactile hallucinations
• Somatic hallucinations
• Liliput hallucinations
d. What is the classification of scizofrenia ?
• Answer :
• Klasifikasi skizofrenia (Maslim & Rusdi. 2013).
• Schizofrenia paranoid
• Schizofrenia hebefrenik
• Schizofrenia katatonik
• Schizofrenia undifferentiated
• Post-schizofrenic depression
• Schizofrenia residual
• Schizofrenia simplex
• Schizofrenia lainnya
• Schizofrenia YTT
e. What are the prodromal symptom from scizofrenia ?
• Answer :
The Diagnostic and Statistical Manual (DSM)-III focuses mainly on observable
behavioral changes in its description of the prodromal features of schizophrenia. It
provides an operationalized criteria of nine symptoms for schizophrenic prodrome:
• Marked social isolation or withdrawal
• Marked impairment in role functioning
• Markedly peculiar behavior
• Marked impairment in personal hygiene and grooming
• Blunted or inappropriate affect
• Digressive, vague, overelaborate or circumstantial speech, or poverty of speech,
or poverty of content of speech
• Odd beliefs or magical thinking
• Unusual perceptual experiences
• Marked lack of initiative, interests, or energy.
7. How to diagnose in the cases?
• Answer :
• Alloanamnesis
• Disturbing the neighborhood.
• Right after cancelled marriage, he started to daydreaming and
withdrawing from society and starting to indotenly going out
and talking less with his family.
• Six month ago, he starting show change personality , he
believes that the neighbors were mocking him behind his back
and he also didn’t want to go the local market because he
believes that the seller also mocking.
• He started to eat less, sedomly takes bath, and his daily
activity was watching television.
• On the previous month, he won’t go out from his home because
he believes that the neighboor are plotting to harm him.
• He sedomly sleep, and every night he always patrolling around
the house to check whether there was spmeone who wants to
harm him
• He didn’t want to takecare himself and only eats being told
• Nassar was known as a smart strudent 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 only child and came from a middle-class family.
• Nassar was known to had cousin who suffers the same
symptom and was hospitalized because of it.
• Autoanamnesis
• He tends to be rowdy, anxious and not cooperative on answering the question given.
• He tends to be angry when being asked and tries to evict the examiner.
• Premorbid History
• Baby : being fed with breast milk until 6 month old, and continued with formulated milk due to
his mother jobs
• Chilhood and adolescence : jolly, had a lot friends , parenting authoritarian mother with
permissive father
• Early adult : jolly with a lot friend
• Medical History
• There is no history of head, NAPZA, fever and other medical condition.
• Psychiatry status
• Appereance : medium postured patient, lack of selft care, eye contact with the interviewer are
exist.
• Attitude and behavior : not cooperative an agitative
• Speaking : fluent verbalization
• Mood : Hypertimc and unstable
• Affect : inappropriate
• Thought : Not realistic, irrelevant, incoherent, delusion (+)
• Perception dissorder : auditoric hallucination (+)
• Reality Testing Ability : Disturbed
• Insight : First grade
• Judgement : Disturbed.
8. How is the differential diagnosis in the case?
• Answer :
1. Paranoid type schizophrenia,
2. Schizoaffective type manic
3. Depression
 
9. How is the investigation in the case?
• Answer :
• No additional examination is carried out because, from
autoanamnesis and alloanamnesis the diagnosis of the disease
can already be enforced
10. How does the diagnosis work in cases?
• Answer :
• Axis I : Paranoid Schizophrenia
• Axis II : Anancastic personality disorder
• Axis III : No physical diagnosis
• Axis IV : Canselled marriage
• Axis V : 20-11
11. How is the case management?
• Answer :
• Pharmacotherapy:
• Antipsychosis : Risperidone 2-8mg / day
• Generation II (atypical) the principle of action does not specifically work on
dopamine receptors and also works on other neurotransmitters, and causes few
side effects when compared to typical antipsychotics.
• In patients using antipsychotic drugs, side effects can be found in the form of:
• Akatisia : subjective feelings can not be silent, restless. One of the most common
EPS
• Tardive dyskinesias: tasting mouth mouth movements, moving neck movements
• Acute dystonia: twisted neck, glared eyes, stiff muscles
• Malignant neuroleptic syndrome: muscle stiffness accompanied by fever and
impaired vital signs
• Mood stabilizer : Litium 800 mg at night.
• Psychotherapy
12. What are the complications in the case?
• Answer :
• Risk of suicide
• Severe depresseion

13. What is the prognosis in a case?

• Answer :
• Dubia ad malam

14. How is the SKDU in the case?

• Answer :
• 3A, is not an emergency
15. What is the view of Islam in the case?
• Answer :
• "Believers and their hearts are at peace with Allah's
remembrance. Remember, only by remembering Allah the
heart becomes at peace "(QS ar-Ra'du: 28).
Conclusion
Nassar, 30 years old experience auditoric hallucination, dellusion,
unhedonia, and withdrawing from the society due to paranoid
schizophrenia, anankastic personality, cancelled marriage and
GAF 20-11.
 
Conceptual framework
f. social f. biology
f. psychology

- Anankastic personality Cancalled

- Parenting disorder marriege genetic

Disturbance in the
hypothalamus

Stimulate adrenal
cortex

Neurotransmitter Dopamine decrease in

Dopamine increases imbalance
in mesolimbic mesocortical

↑Serotonin,
-Unhedonia
Symptom positive ↑Norepinephrine,
-Withdrawal
-delusion ↓Glutamat,
- Audiotoric ↓GABA
halusination
skizofrenia