Republic of the Philippines

Department of Health
Vicente Sotto Memorial Medical Center
Center for Behavioral Sciences
B. Rodriguez St., Cebu City

In Partial Fulfilment of the Requirements in Psychiatry Rotation

(May 16-31, 2019)

BRIEF PSYCHOTIC DISORDER, UNSPECIFIED

MANUEL TIMOTHY JUDE C. LO

University of Cebu School of Medicine
Clinical Clerk-in-Charge

Resident-in-charge:
Dr. Jose Emmanuel Larrazabal
Date: May 24, 2019

Informant and Reliability: Patient’s childhood friend (60%) and Patient (30%)

General Data:
Patient M.J.J., a 28-year-old, female, single, Filipino, a Roman Catholic, currently unemployed,
from Talamban, Cebu City.

Chief Complaint:
“I don’t know why I’m here”, as verbalized by the patient, and “manumbag na siya ug di na maistorya”
as verbalized by the S.O. (her friend)

History of Present Illness:

Approximately 10 years prior to consult, patient was in a relationship with a man who was a drug user.
Patient was influenced by her boyfriend, and became a drug user as well, with history of
methamphetamine and Nubain use since then. At this time, there were no history of behavioural
changes noted.

Approximately 3-4 years prior to consult, patient was seen by one of her friends walking aimlessly in the
streets of Colon, wearing dirty clothes and seemed to have poor hygiene. She was described as
“naghinuktok ug dili na maistorya ug tarong.” No contact was established with the patient and she was
not seen since then.

Approximately 2-3 years prior to consult, patient went to the house of another friend without prior
notice. Patient invited her friend to drink alcohol and do drugs, to which the patient refused. Her friend
tried to distract her by taking her out on a drive. While on the car, her friend persuaded the patient to
stop her drug and alcohol dependence, but patient would just stare blankly, then when she came back
to her senses, she would just say “unsa?” and then would go back to staring afar off. When they went
back to her friend’s house, she immediately escaped and rode a tricycle to an unknown destination. She
was not seen by her friend since. Patient did not display any violent behaviour towards herself and to
her friend at this time.

In the interim, her friends came up with a plan to put their friend in a drug rehabilitation facility to
address her drug addiction. So they contacted a facility at Talisay City to help them in locating the
patient and put her in the said facility.
On the day of consult, patient was then found in a makeshift house together with a man who,
according to the patient’s friend, was in a bad shape as her. Her friends and some of the employees of
the drug rehab facility tried to persuade the patient to go with them, but patient only refused. Patient
was then lured to go with them by going to a drinking spree. She then went with them and afterwards,
she was brought to this institution for consult regarding her condition.

Past Psychiatric History:

Patient has no previous history of psychiatric consults or admissions.
Substance Use/Abuse:
Patient started smoking cigarettes during her first year high school, approximately 13 years old.
Then she started drinking alcoholic drinks at the age of around 14 years old. By this time patient had
drinking sprees with her close high school friends, going to clubs and bars. She drank alcohol to the
point of intoxication.
Patient continued drinking alcohol and smoking until college. Patient was then introduced to
methamphetamine and Nubain by his then boyfriend at that time. Patient since then became a habitual
user of the mentioned substances. There were no noted behavioural changes at this time.
Patient was then well provided by her parents with money, since patient came from a well-off
family. But when patient stopped college, patient had no money to provide herself with the drugs. What
she did is that she would ask drugs from her boyfriend or from her boyfriend’s contacts. Then
eventually, she acquired drugs in exchange for services such as sex. This practice was continued until
present day.
In the present day, patient drinks almost every day to the point of intoxication, and when she is
intoxicated, she would display aggressive behaviour by beating the nearest person. She does not have
any money to provide for her alcohol drinking sprees, but she would drink if she sees a group of people
drinking alcohol and would join them. Patient also continued her smoking habits, consuming one or
more packs of cigarette per day, depending on the money she has. Patient had no history of being
caught by the authorities and no history of admission in a drug rehabilitation facility.

Past Medical History:

Patient is non-hypertensive, non-diabetic, and non-asthmatic. Patient was not known whether
she had past hospitalizations nor surgeries done. Patient also had no known food and drug allergies.

Family History:
Patient is the only daughter by her parents, but currently has half-siblings since patient’s parents
are currently separated and have families of their own. Her parents separated when patient was in
grade school, and since then patient lived together with his father and his new family. The patient and
the informant were not able to give information regarding the half-siblings.
Her mother is currently living in Bantayan with her separated family since they have separated
with her husband. Her father was a seafarer, but then stopped due to an unknown accident happened
while he was working in a ship. Patients’ father is also currently amputated by the leg. They do not know
the current whereabouts of her father. The patient and the informant were not able to provide any
additional information regarding her parents. No known history of suicidal ideation, depressive disorder
or aggressive behaviour on both maternal and paternal side.

Personal/Social History:
Early to Middle Childhood
Patient was born to a then G1P0 mother via NSD, full term, unrecalled birth weight, with no
complications. Both of the parents were the primary caretaker until they separated. Since then, her
father became the primary caretaker and provider for the patient.
 There were limited information on the patient’s early childhood and elementary school days,
since the informant had not yet known the patient that time. What was known is that patient graduated
primary education.
Adolescence
In her adolescent period, patient was home schooled because according to the informant,
patient was very “kiat.” Patient finished only up to third year high school, and then enrolled to ALS and
graduated secondary education. Patient was described as jolly and cheerful, and was the life of the
barkada. Patient had close friends and they often times would go to clubs and bars and have drinking
sprees. By this time the patient started smoking and drinking alcohol. Patient had a car at around 16-17
years old and patient would then use the car for hanging out with friends.
Adulthood
Patient went to a prestigious university in Cebu, and enrolled in Hotel and Restaurant
Management. Patient finished only up to second year, and was not able to continue afterwards. During
college, patient would engage in small buy-and-sell business, ranging from selling small gadgets to
selling cars, and made money out of it. By the time patient went to college, she and her friends would
still see each other but less often due to differences in school and time constraints. By this time patient
met her then boyfriend and was in a relationship for around 2-3 years. According to the informant, the
patients’ boyfriend was a drug user, using methamphetamine and Nubain, and influenced the patient to
use drugs also. Since then, patient would use the drugs regularly, and had money since she was provided
money by her father, and her boyfriend would provide drugs for her. Patient was in an abusive
relationship with his boyfriend, as she was seen with bruises all over her whenever she and her friends
would meet up. In spite of her drug use, patient still remained the jolly and cheerful person she was and
had no behavioural changes by this time.
Patient was noted to have worked in a Korean restaurant at Lahug for around one year. No
other information whether the patient was continuing her vices nor if how she got out of her job.
Currently, patient was found in a makeshift house within the streets of Cebu City, together with
a man who was assumed to be the provider of drugs and her daily needs. The man she was living with
was described as a drug-addict looking. According to her neighbours, the patient would go around and
would randomly join a bunch of people in their drinking sprees. Patient, when intoxicated, would
suddenly show aggressive behaviour and would beat the persons nearest to her.

Sexual History:
Patient is currently single and she identifies herself as a heterogenous female. Age of first coitus
was undetermined. According to the patient, she had been into 2 heterosexual relationships, the first of
which was the boyfriend she had when she was in college. Patient also claimed to have been sexually
active, but was unable to note how many sexual partners she had. No additional information of the
second relationship were provided.

MENTAL STATUS EXAMINATION

Patient is seen conscious, coherent, cooperative, relaxed, wearing a long sleeved shirt and a skirt. Also in
her possession are a dirty, green shirt, a broken cellphone to which she would fidget, and an unlighted
cigarette. Patient appears to have poor hygiene, with dishiveled hair, dirty clothes, dirty fingernails, and
wears slippers. Patient is coughing and would spit just anywhere. However, the patient does not show
any violent behaviour. Patient would oftentimes stare blankly, would look afar off. Patient has euthymic
mood, and has blunted affect. Patient speaks in a well-modulated voice, moderate speech, but most of
the times the patient would just reply “I don’t know” to almost any question being asked of her. Patient
would sometimes mumble inaudibly by herself while staring afar off. Patient denies auditory nor visual
hallucinations, nor any suicidal ideations and suicide attempts. Patient displays thought blocking. Patient
is oriented to person, but not oriented to place and time. Patient’s remote, recent past, recent memory
is poor, but her immediate memory is fair. Her concentration is fair, being able to do simple
mathematical calculations, but then would stop after three questions and say “I don’t know.” Patient
has poor insight of her condition, saying “I don’t know why I am here.” Patient has poor abstract
reasoning and poor judgement.

CLINICAL FORMULATION

Primary Impression: Psychotic disorder, unspecified is considered since the patient presents with
hallucinations, and has impairment in her hygiene and in interpersonal relations, which are criteria for
psychotic disorders in general. However, since the last contact with the patient, according to the
informant, was at least two years ago, and within this time frame, the symptoms of psychosis was not
established, such as if the symptoms were present continuously within at least 6 months. According to
the DSM-V, this diagnosis “applies to presentations in which symptoms characteristic off a schizophrenia
spectrum and other psychotic disorder that cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning predominates but does not meet the full criteria
for any of the disorders in the schizophrenia spectrum and other psychotic disorders diagnostic class.”
The criteria for schizophrenia is enumerated in the differential diagnoses.

Differential diagnoses:

1. Schizophrenia – this diagnosis is considered since patient presents with negative symptom such
as blunted affect, hallucinations, impairment of functioning such as proper hygiene and
interpersonal relations, and the condition has been present for approximately 3 years, according
to the informant. This diagnosis, however, cannot be entirely ruled out since the patient’s
symptoms is more associated with the use of substance, and it was not known in the span of the
two-year period since last contact of the informant to the patient whether the symptoms are
still present or not.
2. Substance abuse disorder - this diagnosis is considered since the patient present with symptoms
of negative symptoms, hallucination, and impairment of functioning, as elaborated above, and
patient has a history of substance use and abuse, and currently, the patient is still using the
substances as claimed by the informant. However, this diagnosis cannot be entirely ruled out
since the history of drug use is not very specific and does not reveal whether the patient has
been using substances within at least one month period, which is one of the criteria in DSM-V
for diagnosis of Substance abuse disorder.
 3. Brief psychotic disorder – this diagnosis is considered since the patient presents with
impairment of functioning, and hallucinations. However, this diagnosis is least likely since there
has been no information regarding as to when the symptoms appeared and its duration, and
there has been no recent life event that could have been a trigger to developing this condition.
The duration should be at least one day, and may spontaneously resolve within a month since
the onset of symptoms.

Therapeutic plans:

1. Treatment of psychosis – patient was given Risperidone 2mg/tab, as a treatment to patient’s

symptoms. This medication belongs to the atypical antipsychotic class, which acts on the
dopaminergic D2 receptors and serotonergic 5-HT2A receptors in the brain. This is given as a
treatment for patient’s symptoms of psychosis.
2. Patient is not a candidate for admission since the patient does not pose a risk for suicide nor
homicide. However, patient has prior history of causing harm to other people within the
community. So, patient is observed if patient still displays aggressive behaviour towards other
people.
3. Admission to a drug rehabilitation facility may be a need since the patient has history of
substance abuse. Patient can be observed for any changes in behaviour, withdrawal symptoms,
and activities that can help the patient not to be dependent to substance use.
4. Counselling of family members is needed to provide support for the patient as she is being
treated for the illness.