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MUHIMBILI UNIVERSITY COLLEGE OF HEALTH

SCIENCES

DEPARTMENT OF PSYCHIATRY

SUPERVISOR: DR.KAAYA

WRITE UP OF TABU MAULIDI

Shaina Yusuf & Benela Zavery


MD5 (group A1)
Semester 9-10
INTRODUCTION:

Name: Tabu Maulidi


Sex: Female
Age: 36 years
Residence: originally resided in Dar-es-salaam: Mtoni, but was residing in
Morogoro when her illness was discovered.
Occupation: petty trader (selling chicken and chips).
Marital status: recently widowed, 6 children with 3 different men.
New case admitted on 20th March 2006.
Informants: patient, brother and sister of patient.
Additional information obtained from her inpatient file.

Main complains: hearing of voices for 4 years. However, siblings complain


of her abnormal behavior 2 weeks prior to her admission.

History of present illness:


Tabu was well until 4 years ago when she started hearing voices of people of
both genders, which were not recognizable, and others around her could not
hear them. The voices told her normal daily life events, things to do for her
betterment and to avoid things that may harm her. She was also told that she
would be very successful, rich and famous. She considered theses voices to
be a normal thing and was not feeling threatened about them. The frequency
and intensity of heari8ng voices gradually increased with time, mostly being
at nighttime before she went to sleep. Later the voices told her to become a
traditional healer, so that she could help people around her with problems
such as HIV. She normally followed what the voices told her to do, however
when she was told to become a traditional healer she was reluctant. One
night she dreamt of her deceased father bringing her a bag of healing
materials and ordered her to become a traditional healer whereby she asked
her brother to help her find herbs so that she would start healing people. Her
brother realized there was something wrong with her but did not know what
to do and tried to convince her not to fulfil everything she dreamt. During
these periods she denied seeing, smelling, tasting or feeling things that
others did not see, hear, feel or see. The voices did not hinder her normal
daily activities. She denies any thoughts or actions of harming others or
herself.
In December last year her husband got ill and he decided to go to his
home-village in mafia to his family when his family called him for further
management there, as he was not feeling better after being treated here
several times, he was loosing weight and feeling weak. She was left behind
alone with her 2 last born children, the reason for her not going with her
husband was that there were a lot of evil spirits in Mafia and he did not want
his wife and children to be affected by witchcraft so he suggested she stayed
here.
Early January the voices told here that her husband will die. Third
week of January she received a message from a relative that her husband had
passed away. She then went to her mother’s home in Morogoro for the
rituals 40 days. She did not go to Mafia to her husband’s family because she
does not know how to get there; she has never been to her in-laws.
Two weeks prior to admission when she was still at Morogoro she
started to behave abnormally becoming aggressive, demanding to be allowed
to be a traditional healer, she did not want anyone to come close to her
except her elder brother who she used to be emotionally attached as they
lived in the same town. She had become very uncooperative with abusive
language, liked sitting alone, could not fall asleep and did not like eating.
There is no history of cigarette, cannabis or drug use but occasionally she
took a bottle or two of beer.

Review of systems:
Cardiovascular system:
There was no awareness of heartbeats, no chest pain.

Respiratory system:
No difficulty in breathing, no coughing, no cyanosis.

Gastro-intestinal system:
There’s loss of appetite, no constipation, no diarhoea, no vomiting/nausea.

Central nervous system:


No history of loss of consciousness, no convulsions, no dizziness or blurred
vision.

Past medical history:


Tabu has never been admitted for any medical or surgical conditions
before. She had malaria infection 2 weeks prior to admission (85
trophs/200WBC) which was treated with quinine.
Past psychiatric history:
This is her first psychiatric admission where psychiatric services are
sought.

Family social history:


She is 5th child out of 12 children from her biological parents.
Her mother is alive and well, subsistent farmer in Morogoro taking care of
her 2 children from her 1st husband.
Her father died in 2004 of unknown cause. He was not ill. Her father was an
occasional alcohol drinker but would not drink to the extent of passing out.
He was close to Tabu and was not abusive verbally or with actions.
There is no family history of asthma, cancer, hypertension, diabetes or
psychiatric disorders.
Her family is showing support to her and they visit her daily, bringing her
clean washed clothes, food and drinks. They are ready to assist Tabu in any
ways to help her get better.

Personal history
Tabu was born in 1970. When she was born the family was going through
financial crises and her mother got ill to the extent that she got admitted
while her aunt was taking care of Tabu thus, her name.
She started school when she was 8yrs old; she was not performing well in
school as she used to take biting (vitumbua/maandazi) to school for sale. She
liked to be alone but used to have 3 close friends out of which one was an
average student while the rest were failing like her. She used to like playing
skipping rope and occasionally basketball. She finished standard VII at age
of 15years but did not get selected. There is no history of being in trouble
with school authority.
After finishing standard VII she worked with her mother and within few
months time she opened her kiosk; selling fried chicken and chips.
Her uncle was to travel so he asked Tabu to come help him with his
restaurant where she was raped by one of the staff resulting her to be
pregnant. She decided to live with this man despite the fact she did not love
him.
By age of 20years, she was a mother of 4 children. Her husband was an
alcoholic getting drunk almost everyday, coming back home between 1-3am
and forcing her to have sex with him resulting her getting pregnant every
year.
In 1990 they both decided to separate, her husband remaining with their
older two daughters while she took custody of the younger two sons while
staying with her mother in Morogoro after which they have never met again.
In Morogoro she helped her mother and worked as a subsistent farmer for 6
months but she did not like working in the farm so she decided to open her
kiosk of selling fried chicken and chips in Mtongani where she also rented a
room.
In 1993 She met a man with whom she started living with while running her
business successfully. She had a child with this man who had similar alcohol
problems like the previous man of hers so she decided to separate with him
in 2000 taking responsibility for her child. After her separation she
continued well with her business.
Three years ago she met her deceased husband who lawfully married her and
had a child with him a year later. About two years after her marriage her
husband had confessed to her that he had raped his cousin and impregnated
her for which his family has not been in good terms with him. When her
husband got ill she as well her husband believed that he was bewitched by
his family for the rape, thus his death. The siblings of Tabu report the
husband to have been suffering from pulmonary tuberculosis and dying of it.

Premorbid personality:
Before the onset of this illness, Tabu liked to do this on her own, liked
listening to music while she did her chores after work. She was hard
working woman and she liked her work. She had few friends with whom she
had good relations.

Present living circumstances:


She was more of an introvert person liking to be home, doing things on her
own. She denies liking going out with friends to parties and gatherings. She
liked her work and was satisfied with her well-going business. She
occasionally took a beer or two when she felt like it otherwise she did not
use any other substances.
Tabu agrees to have multiple sexual partners before and during her marriage
excuse being that her husband had several sexual partners as well she had
suspected, so she looked for care and love outside her marriage.
After work she liked to be home, listen to music while she did her
housework.
On examination:
Tabu was a young lady with good nutritional status, afebrile, no oral thrush
no lower limb edema and no lymphadenopathy. On systemic examinations
of cardiovascular system, respiratory, para abdomen and musculo skeletal
systems were normal.

Mental status evaluation:


Appearance: well-groomed, middle aged woman who was fully conscious
but avoided eye contact. Her posture was normal and had no abnormal
movements.

Speech: her flow of speech was slow with low volume but normal tone. Her
words were meaningful.

Mood and affect: she looked and sounded down with blunt affect on
inquiring about her reaction about her husband’s confession for raping his
cousin.

Thought: No flights of ideas, quantity of thoughts were normal and logical,


content was normal too and was not dominated by her own thoughts.

Perception: she had 2nd person auditory hallucinations considering her


surrounding environment normal and she did not have delusions.

Sensorium: she was oriented to time, person and place. She had normal
immediate, recent and descent memory.

Cognitive function: she was concentrating well while talked to, she could
substract 3 from 20. she could count 1-10 and 10-1. She could name 5
objects immediately, after2 minutes and 5 minutes correctly.

Insight: Tabu thinks she’s normal and was wondering why she was brought
in psychiatric ward.

Judgement: when given the situation of fire in the house with a child she
could judge well to take her child and escape to save their lives.
Etiological formulation:
Vulnerability factors:
Early childhood stress when mother got ill to the extent of not being able to
be fed.
Poor school performance
Working since childhood

Precipitating factors:
Rape
Early unwanted pregnancy
Two separations
Alcoholic partners
Multiple sexual partners

Maintaining factors:
Loneliness
Unable to work

Descriptive formulation:
Tabu maulidi, 36 years old living in Mtoni until January 2006 when her
husband passed away due to PTB when she started living in morogoro with
her mother. She was brought to MNH by her brother with complains of
abnormal behavior 2 weeks prior to admission characterized by insomnia,
lack of appetite, irritable and aggressive to family members. She had 2nd
person auditory hallucinations for 4years. She has history of multiple sexual
partners raped at age 15 years. She drinks beer 1-2 bottles occasionally but
there is no history of substance use, father used to drink alcohol but not get
drunk.

Diagnostic formulation:
Depressive psychosis
2nd person auditory hallucinations
Insomnia
Loss of appetite
Sitting alone
Blunt affect
Lack of insight
Management:

Short term treatment:


• Tab haloperidol 4.5mg bd for 2 weeks
• Tab amitryptiline 50mg nocte for 2weeks
• Tab valium 20mg nocte for 3days

Long term treatment:


• Motivational assessment
• Psychotherapy for better insight
• Occupational therapy
• Family sessions

Prognosis:
The prognosis for Tabu is not very good due to her 2nd person hallucinations and
poor eye contact. As she has poor insight to her disorder she might not be adherent to her
medications.
She is not allowed to do any work at the moment by her family so she sits alone
most of the time giving her more chance to think and be occupied with her hallucinations
and delusions.

Progress in the ward:


Tabu had been in acute ward for 5 days, after which when she was calm and less
irritable she was transferred to general female ward. She was on regular medication but
her insight remained poor and so did her eye contact. She also continued to have 2nd
person auditory hallucinations. On the 5th day she had escaped for 7 hours (13:00-
20:00hours) and was found to be roaming around the old peadiatric wards, but she was
calm when she was found and brought back to the general wards.
On 4th April (15 days post admission) she still had poor insight, poor eye contact
and 2nd person auditory hallucinations thus haloperidol was increased to 4.5mg bd plus
3mg nocte and amitryptiline to 75mg nocte but her symptoms persisted.
Last seen on the 12th April (23 days post admission) she persisted with all the
three problems mentioned above but she was calm and talked well. She was complaining
that she was harassed by her mates and she wanted to go home.
On April 15th (26 days post admission) she was visited by her siblings who later
were convinced that she was well and wanted to tale her home. Tabu wanted to go home
as well. Despite being told by the nurse incharge that she will be absconding the
psychiatric services, the siblings took Tabu home.