SCENARIO B BLOCK XIV

“STOP MOCKING ME”

Tutor : dr. Nyayu Fitriani, M.Biomed.

Group 6
1. Derry Nuansa Ilham (702017021)
2. Fajar Al-Farabi (702017031)
3. Melisa Nopa Belia (702017014)
4. Muhammad Ichsan Pradipta (702017063)
5. Thesa Lonica (702015002)
6. Yosi Anggraini (702017007)
7. Meri Oktarina (702017084)
8. Vera Novita Sari (702017065)
9. Septi Fadhillah Sarabayan Pazka (702017053)
10. Meysa Rosalina Agda (702017022)

FACULTY OF MEDICINE
MUHAMMADIYAH PALEMBANG UNIVERSITY
2019

1
 DAFTAR ISI

Kata Pengantar ................................................................................................. i

Daftar Isi .......................................................................................................... ii
CHAPTER I : PRELIMINARY
1.1.....................................................................................................................Back
ground ........................................................................................................ 1
1.2.....................................................................................................................Purp
ose .............................................................................................................. 2
CHAPTER II : DISCUSSION
2.1.Tutorial Data .............................................................................................. 5
2.2.Case Scenario ............................................................................................. 5
2.3.Term Clarificartion .................................................................................... 7
2.4.Identification of Problem............................................................................ 8
2.5.Analisi ........................................................................................................ 10
2.6.Conclusion ................................................................................................. 41
2.7.Conseptual Framework............................................................................... 41
Reference ......................................................................................................... 43

2
 CHAPTER I
PRELIMINARY
1.1. Background
The Soul Medicine Block and the Sublime Function are the fourteenth block
in semester V of the Curriculum Based on Medical Education Competency,
Faculty of Medicine, Palembang Muhammadiyah University. On this occasion a
scenario A case study tutorial was held on the case of 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 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 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.

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

4
 CHAPTER II
DISCUSSION
2.1. Tutorial Data
Tutor : dr. Nyayu Fitriani, M. Bmd.
Moderator : Derry Nuansa Ilham
Secretary Desk : Yosi Anggraini
Board Secretary : Meysa Rosalina Agda
Time : Monday, September 16 2019
At 08.00-10.00 WIB
Wednesday, september 18 2018
At 08.00-10.00 WIB
Rule of tutorial:
1. Turn off the cellphone or in a state of silence.
2. Hold up your hand when you will make an argument.
3. Permission when going out of the room.
4. Food and drink are prohibited.

2.2. 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

5
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.

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

2.3. Term Clarification

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 ability Physotherapeutic function by which of the object or
real world
Perfectionist People who wanted everything to be perfect
Daydreaming Condition when someone mind breaks with the

7
 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

2.4. Identification of Problem

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.
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.
3. 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 himself, and only eats when being told .
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.
5. Autoanamnesis

8
 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.
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

9
 Time-place orientation : normal
Reality testing ability : disturbed
Insight : first grade
Judgement : distrubed

2.5. Analisi
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 :
Limbic System
1) NeuroAnatomic

Gambar
2.1 Sistem
Limbik
(Baehr
&Frotscher, 2016)

10
 Because of advances in neuroscience, the structures included in the
limbic system have undergone redefinition multiple times. However, the
structures included in the limbic system are in the general region that borders
the cerebral hemisphere and brainstem, lateral to the thalamus, underneath the
cerebral cortex, but above the brainstem. The particular embryologic origins
can separate the currently defined major structures of the limbic system. The
mesencephalic components are from visual, auditory and somatosensory
inputs processed in the region. The diencephalic components are the
hypothalamus, anterior thalamic nuclei, and habenular commissure. The
telencephalic components contain the cortical and subcortical regions; which
are the olfactory bulbs, hippocampus, parahippocampal gyrus, fornix,
columns of the fornix, mammillary body, septum pellucidum, amygdala,
cingulate gyrus, entorhinal cortex (Torrico & Abdijadid, 2019)
While the limbic system was initially suggested to be the sole
neurological system involved in regulating emotion, it is now considered only
one part of the brain to regulate visceral, autonomic processes. In general, the
limbic system assists in various processes relating to cognition; including
spatial memory, learning, motivation, emotional processing, and social
processing (Torrico & Abdijadid, 2019)
Hypothalamus
The hypothalamus plays many roles in maintaining homeostasis.
However, its role in the limbic system receives less attention. Connections
between the hypothalamus, nucleus accumbens, ventral tegmental area,
hippocampus, and amygdala have been established. The neural interface
between these structures is essential for behaviors such as food-seeking and
escape and fear from predators. This interface has been described as the
“limbic-motor interface,” it is a model for the initiation of actions by limbic
forebrain structures and helps explain how the “emotive brain” and “cognitive
brain” operate together to initiate a response (Torrico & Abdijadid, 2019).
The olfactory bulbs are involved in the sense of smell. They transfer
olfactory information to the amygdala, orbitofrontal cortex, and hippocampus

11
for processing. The amygdala then processes this information and uses it for
associative learning. For example, by encoding odor cues associated with a
positive or negative taste (Torrico & Abdijadid, 2019).
Hypocampus
The hippocampus is an allocortical structure that is important for the
consolidation of information, including short-term, long-term and spatial
memory. People with extensive bilateral hippocampal damage are likely to
have anterograde amnesia, as demonstrated in the infamous case of “H.M.”
Schizophrenic patients have been reported to have reductions in the size of
their hippocampi. Additionally, in Alzheimer disease, the hippocampus
suffers damage resulting in short-term memory loss and disorientation.The
parahippocampal gyrus is the cortical region surrounding the hippocampus
with roles in scene recognition, and memory encoding and retrieval. Like the
hippocampus, the parahippocampal gyrus has been observed to be
asymmetrical in patients with schizophrenia (Torrico & Abdijadid, 2019).
The fornix is the major output tract of the hippocampus. Its exact
function is not clear, but lesions along the fornix have been shown to cause
problems with recall memory.The columns of the fornix end at the
mammillary bodies. The mammillary body has limbic connections with the
amygdala, hippocampus, and anterior thalamic nuclei. The mamillary bodies
are important for episodic memory. Thiamine deficiency has been well
described in causing damage to the mammillary bodies, most commonly
through Wernicke-Korsakoff syndrome (Torrico & Abdijadid, 2019).
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. Additionally, the
amygdala further processes memory and decision-making. Fear conditioning
processing takes place in the lateral nuclei of the amygdalae where memories
form associations with the adverse stimuli though long-term potentiation.
Damage to the amygdalae has resulted in the impairment of fear conditioning.

12
Klüver-Bucy syndrome is another rare condition observed after bilateral
lesions to the amygdalae occur. Symptoms include amnesia, docility,
hyperphagia (both pica and overeating normal foods), hyperorality,
hypersexuality, and visual agnosia (Torrico & Abdijadid, 2019).
2) Neurotransmitter
a) Norepinefrin
Patients who can improve the adregenic system that regulates
poorly with activities that sometimes occur. The body of the
noradregenic system is located at the location where you are under the
rostalis and this cell body extends its axons to the cerebral cortex,
limbic system, brain stem, and spinal cord (Kaplan, 2010).
b) Serotonin
Serotonergic neuron cell bodies are located beneath the rostal brain
stem nucleus and channel impulses to the cerebral cortex, limbic system
(specifically the amygdala and hippocampus) and hypothalamus
(Kaplan, 2010).
This neurotransmitter, also known as 5hydroxytryptamine (5HT), is
synthesized from tryptophan by the enzymes tryptophan hydroxylase
and aromatic amino acid decarboxylase. It binds to two types of
receptors: serotoningated ion channels (5HT3 receptors) or G protein–
coupled receptors (5HT1, 5HT2, and 5HT4–7 receptors). The body of
most serotonin neurons is located in a series of nuclei—known as the
raphe nuclei—that are shaped like a seam and are located in the brain
stem (see figure 3). Some serotonergic projections from these nuclei
descend to the spinal cord where they modulate pain transmission.
Other projections ascend to brain regions such as the cortex,
hippocampus, and hypothalamus . In the mature brain, the serotonin
neurotransmitter system is involved in the regulation of mood,
attention, appetite, sleep, and other functions. Alterations in this
neurotransmitter system have been linked to neuropsychiatric
conditions, including depression. Serotonin is removed from synapses

13
 via reuptake mediated by transporters in the axon terminals, which are
inhibited by antidepressant medications such as fluoxetine . Serotonin
neurons are expressed early in development (embryonic day 12 in
rodents), and serotonin released from these neurons has been shown to
control progenitor cell proliferation, differentiation, migration, and
synapse formation (Frederick and Stanwood , 2009). Therefore, the role
of alterations in this transmitter system in FASD has been investigated
in several laboratories, as these alterations could have a wide impact on
neuronal circuit development across different brain regions (Valenzuela
et al, 2011).
c) Dopamine
inhibits its nature in the basal ganglia and excitation in the frontal
cortex. This biogenic amine transmitter is synthesized from tyrosine by
the enzymes tyrosine hydroxylase and Laromatic amino acid
decarboxylase. Dopamine binds to five types of G protein–coupled
receptors that are grouped in two families: D1like receptors (D1 and D5
receptors) and D2 like receptors (D2, D3, and D4 receptors). The action
of dopamine is terminated by reuptake into axonal terminals via
dopamine transporters. The cell bodies of dopaminergic neurons are
located in the hypothalamus and in brain stem regions known as the
substantia nigra pars compacta and the ventral tegmental area (see
figure 3). Dopaminergic fibers project extensively throughout many
brain regions, including the cortex, hippocampus, and striatum. In the
mature brain, dopamine is involved in the regulation of movement,
attention, motivation, and reward. Alterations in this neurotransmitter
system have been linked to neurological disorders, such as Parkinson’s
disease (caused by degeneration of substantia nigra pars compacta
dopaminergic neurons), as well as neuropsychiatric conditions such as
schizophrenia, attention deficit disorder, and substance abuse. In the
developing brain, dopamine regulates neuronal differentiation,

14
 migration (including that of GABAergic neurons), and axonal and/or
dendritic growth (Frederick and Stanwood, 2009).
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 (Sherwood, 2014).

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 possitive and negative symptoms in schizophrenia ?

Answer :
Possitive symptoms : any change in behaviour or thoughts, such as
hallucinations or delusions
 Hallucinations are where someone sees, hears, smells, tastes or feels
things that don't exist outside their mind. The most common
hallucination is hearing voices. Hallucinations are very real to the person
experiencing them, even though people around them can't hear the voices
or experience the sensations.
 A delusion is a belief held with complete conviction, even though it's
based on a mistaken, strange or unrealistic view. It may affect the way
the person behaves. Delusions can begin suddenly, or may develop over
weeks or months.
 Confused thoughts (thought disorder)
People experiencing psychosis often have trouble keeping track of their
thoughts and conversations. Some people find it hard to concentrate and

15
 will drift from one idea to another. They may have trouble reading
newspaper articles or watching a TV programme.
 Changes in behaviour and thoughts
A person's behaviour may become more disorganised and unpredictable,
and their appearance or dress may seem unusual to others. People with
schizophrenia may behave inappropriately or become extremely agitated
and shout or swear for no reason.

Negative symptoms that are shown in schizophrenics are as follows (Hawari,

2010):
 Nature of feeling (afect) "blunted" and "horizontal". This feeling of
nature can be seen on his face that shows expression.
 Withdraw or isolate yourself (withdrawl) do not want to hang out or
contact with other people, like daydreaming (day dreaming).
 Emotional contact is very "poor", difficult to talk to, quiet.
 Passive and apathetic, withdrawing from social interaction
 Difficult in abstract thinking.
 Stereotypical mindset.
 There is no / loss of impulse (avolition) and no initiative, no effort, no
spontaneity, monotony, and do not want anything and and do not want
anything and are lazy (loss of lust).

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.  His daughter Anna (1936) developed these
ideas and elaborated on them, adding ten of her own.  Many psychoanalysts
have also added further types of ego defenses. Mental defense mechanism in
Freud's psychoanalytic theory (Sadock, 2010) :

16
a) Mental defence mechanism level 1 :
1) Denial
The self denial of one’s feelings or previous actions is one defence
mechanism to avoid damage to the ego caused by the anxiety or guilt of
accepting them. 
2) Distortion, is an obscured external reality to fulfill internal desires.
3) Primitive idealization, is an object seen in the extreme category "totally
good" or "totally bad"
4) Projeksion, is an internal impulse and its derivatives are unacceptably
perceived as if they never arose in us and are delegated to others
5) Projective identification, is aspects that are not desired "thrown" to others
so that individuals who make these projections feel to be one with the
object of his project.
6) Splitting.
Splitting occurs when the ego attempts to reconcile multiple aspects or
rationales, but resorts to understanding the world in “black and white”
terms. A person who experiences splitting may take an “either-or”
approach when making evaluations of the world around them, including
objects, situations, and people. They tend to view ideas as either right or
wrong, with no middle ground or compromise. Similarly, they may take a
“good versus bad” approach in relationships, admiring one group of people
whilst completely rejecting those who do not live upto their expectations.

b) Mental defence mechanism level 2

1) Fantasy, a tendency to run into fantasy to resolve conflicts within
(internal) and the external world (external)
2) Projeksion, is an internal impulse and its derivatives are unacceptably
perceived as if they never arose in us and are delegated to other
3) Hipokondriasis, is the transformation of negative feelings towards others
into negative feelings toward oneself, pain, illness and anxiety
4) Passive aggression.

17
 Displays of aggression are considered unsociable and undesirable in
many societies, so when aggressive or violent impulses are experienced,
people tend to avoid them as much as possible. However, the remaining
energy driving such aggression may prove to be more difficult contain,
and may manifest in other forms, known as passive aggression. A passive
aggressive person may be uncooperative in carrying out their duties or
other tasks, may deliberately ignore someone when spoken to and might
adopt a negative view of their situation, such as their job, and of those
around them (e.g. colleagues).
5) Acting out.
When the id component of the human psyche signals the desire to act on
an impulse, the ego and super ego will often counteract it if they feel that
that behavior would be counterproductive or immoral. A person may
want to curse after falling over in a busy street, but the ego, perceiving
this as contradicting social etiquette, will often lead to them holding back
on the expletives. On some occasions, however, we may not be able to
balance the impulses of the id and will defend the ego by simply acting
out the irrational desires. For example a person might “act out” by
theatrically storming out of a stressful meeting when they would
otherwise stay calm and hide their unease.
6) Idealisation involves creating an ideal impression of a person, place or
object
by emphasising their positive qualities and neglecting the those that are
negative. Idealisation adjusts the way in which we perceive the world
around us and can lead us to make judgement that support our idealised
concepts. People often idealise their recollections of being on holiday or
memories from childhood, seeing them as ‘happier times’, but fail to
recollect arguments or stresses during those periods. We often idealise
the image we hold of people we admire - relatives, partners or celebrities,
making excuses for their failures and emphasising their more admirable
qualities.

18
7) Identification.
According to Freud’s concept of the Oedipus Complex, a child may
experience feelings of resentment towards their father as they compete
for the affection of their mother and the resulting castration anxiety - an
irrational fear directed towards the father - may lead them to feel the need
to appease the father. In order to pacify a person whom we perceive to be
a threat, we may emulate aspects of their behavior. By adopting their
mannerisms, repeating phrases or language patterns that they tend to use
and mirroring their character traits, a person may attempt to appease a
person. This defense mechanism was described by Anna Freud as
identification with an aggressor. A person moving schools or countries,
starting a new job or entering a new social circle might adopt the social
norms or attitudes of classmates, neighbors, colleagues or other people
whom they seek acceptance from, for example, in order to avoid being
rejected by their new peers
8) Introjection.
Introjection occurs when a person takes stimuli in their environment and
adopts them as their own ideas. This may involve internalising criticism
from another person and believing the other person’s points to be valid.
A person may introject religious ideas that they have heard at church, or
political opinions that friends espouse. Behavior can also be introjected -
the mannerisms of a father may be observed by his son and then
replicated.
9) Regression.
Regression occurs when a person reverts to the types of behavior that
they exhibited at an earlier age. Stress of adult life and the associated
anxiety may lead to a person seeking comfort in things which they
associate with more secure, happier times. They might regress by eating

19
 meals that they were given as a child, watching old films or cartoons,
acting without thought for the consequences of their actions.
10) Somatisasi. The somatization defence mechanism occurs when the
internal conflicts between the drives of the id, ego and super ego take on
physical characteristics.
c) Mental defence mechanism level 3
1) Displacement

Displacement is a mechanism that changes the target of sexual drive or

aggressiveness to other targets that are more acceptable or less dangerous
2) Isolation defense mechanisms in the theory of psychoanalysis were first
proposed by Sigmund Freud. While related to repression, this concept
distinguishes itself in several ways. It is characterized as a mental process
that involves creating a gap between unpleasant or threatening cognition,
and other thoughts and feelings.
In the case he experiences mental defense level 2 and 3 is rhe 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 (Kaplan & Sadock,
2010).

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)

20
21
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 (Elvira, 2017).

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 (Sadock, 2014) :
Classification of Delusional :
1) Bizar delusion : wrong and strange beliefs, very unreasonable.
Example: an intruder from outer space has implanted electrodes into his
brain
2) Systematic delusion : false beliefs or beliefs united by a single event or
theme.
Example: feeling chased by the CIA, the FBI or the mafia.
3) Congruent-mood delusions: delusions whose contents match the mood.
Example: depressed patients who believe that they are responsible for the
destruction of the world.
4) Nihilistic delusion : a false feeling that he, others, and the world does not
exist or will come to an end.

22
 5) Poverty delusion: false belief in someone that he is broke or will lose all
his belongings.
6) Somatic delusion : false beliefs involving bodily functions.
Example: feeling sick when normal.
7) Paranoid delusions :
- Being pursued delusion false belief in someone who feels that he is being
harassed, suspected, or pursued.
- Greatness delusion : his identity is exaggerated.
- Referrals delusion : a false belief in someone that the behavior of others
is shown to him, derived from the idea of referral.
Example: the belief that people on TV and radio talk to or about
themselves.
8) Controlled delusion : a false feeling that one's desires, thoughts or feelings
are controlled from the outside.
- Thought withdrawn: understanding that a person's thoughts are removed
from him by other people or forces.
- Thought insertion: understand that a thought has been entered into one's
brain by someone or another power.
- Thought broadcasting: understand that a person's thoughts can be heard
by others
9) Thought control: understand that a person's thoughts are controlled by
others.
10) Jealousy delusion : wrong beliefs that originate from a person's
pathological jealousy that his lover is unfaithful.
11) Erotomania: feeling someone is in love with him.

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.

23
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 The Diagnostic and
Statistical Manual (DSM)-III-R (American Psychiatric Association 1987)
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:
1. Marked social isolation or withdrawal
2. Marked impairment in role functioning
3. Markedly peculiar behavior
4. Marked impairment in personal hygiene and grooming
5. Blunted or inappropriate affect
6. Digressive, vague, overelaborate or circumstantial speech, or poverty of
speech, or poverty of content of speech
7. Odd beliefs or magical thinking
8. Unusual perceptual experiences
9. Marked lack of initiative, interests, or energy.

24
e. How to mechanism additional complain ?
Answer :

F. Social
(cancel merried)

Disturbance in the
hypothalamus

Stimulate HPA axis

(CRH)

Stimulate anterior pituitary

(ACTH)

Stimulate adrenal
cortex

Neurotransmitter
imbalance

Dopamine increases Dopamine decrease

in mesolimbic in mesocortical

Positive Symptoms Negative Symptoms

Hallucination
Delusion Unhedonia
Withdrawal

25
 f. What is the possibility disease with chief complain ?
Answer :
- Schizophrenia is a form of psychotic disorder that shows several
psychotic symptoms, coupled with other stories such as time period,
consequences of the disorder and do not overlap with other similar
disorders. Psychotic patients cannot recognize or have no contact with
reality. Some psychotic symptoms are delusions, hallucinations, chaotic
speech, chaotic behavior (Kaplan & Sadock, 2009).
- Schizoaffective is a mental disorder characterized by a combination of
symptoms of schizophrenia (impaired thinking, delusions and
hallucinations) and affective symptoms (depressive or manic symptoms).
These affective symptoms can also be called mood symptoms (Kaplan &
Sadock, 2009).

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 :

26
 Genetic Stressor Anankatis
personalit
y
Disfunction/
imbalance
nurotransmitter

↑Dopaminergic
(Mesolimbic pathway),
↓Dopaminergic
(Mesocortical pathway),
↑Serotonin,
↑Norepinephrine,
↓Glutamat,
↓GABA

Negative Possitive
Signs

Hallucinatio
Timid and n&
reserve, not Delussion
to go to the
collage,
often spent
his time
watching
the
television,
The meaning is hyperactive behavior due to paranoid delusions.
c. What in the mechanism of his complaint ?
Answer :

27
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.

28
 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 :

F. GENETIK F PSIKOSOSIAL

SCIZOPHRENIA

DOPAMINE
DISTURBANCE

DOPAMINE DOPAMINE
INCREASE IN DERCREASE IN
MESOLIMBIC MESOCORTICAL

POSITIVE NEGATIVE
4. Before this SYMPTOMS SYMPTOM

complaint, Nassar
Decrease in self-
was known care function as a
smart student
in school, and tend to be perfectionist. Nassar used to be a civil servent, but he

29
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 relation of perfectionist with complaint ?

Answer :
Perfectionism is driven by fear (paranoia) of failure to please others and fear
of rejection and criticism. Therefore, perfectionists will take various measures
to ensure that everything is up to the point where perfectionism is an
anecastic personality trait (Maslim, & Rusdi, 2013).

c. What is the classification of personality disorder?

Answer :
Classification of personality disorder (Sadock, 2014) :
1) Paranoid Personality Disorder

The Paranoid Personality Disorder is characterized by a

pervasive distrust and suspiciousness of other people.
- People with this disorder assume that others are out to harm them,
take advantage of them, or humiliate them in some way.
- They put a lot of effort into protecting themselves and keeping their
distance from others.
- They are known to preemptively attack others whom they feel
threatened by.
- They tend to hold grudges, are litigious, and display pathological
jealously.

30
 - Distorted thinking is evident. Their perception of the environment
includes reading malevolent intentions into genuinely harmless,
innocuous comments or behavior, and dwelling on past slights.
- For these reasons, they do not confide in others and do not allow
themselves to develop close relationships.
- Their emotional life tends to be dominated by distrust and hostility.
2) Schizoid Personality Disorder

The Schizoid Personality Disorder* is characterized by a pervasive pattern

of social detachment and a restricted range of emotional expression. For
these reasons, people with this disorder tend to be socially isolated. They
don't seem to seek out or enjoy close relationships.
- They almost always chose solitary activities, and seem to take little
pleasure in life.
- These "loners" often prefer mechanical or abstract activities that
involve little human interaction and appear indifferent to both
criticism and praise.
- Emotionally, they seem aloof, detached, and cold.
- They may be oblivious to social nuance and social cues causing them
to appear socially inept and superficial.
- Their restricted emotional range and failure to reciprocate gestures or
facial expressions (such a smiles or nods of agreement) cause them to
appear rather dull, bland, or inattentive.

3) Schizotypal Personality Disorder

Persons with Schizotypal Personality Disorder* are characterized by a

pervasive pattern of social and interpersonal limitations. They
experience acute discomfort in social settings and have a reduced
capacity for close relationships. For these reasons they tend to be
socially isolated, reserved, and distant.

31
 - Unlike the Schizoid Personality Disorder, they also experience
perceptual and cognitive distortions and/or eccentric behavior.

- These perceptual abnormalities may include noticing flashes of light

no one else can see, or seeing objects or shadows in the corner of their
eyes and then realizing that nothing is there.

- People with Schizotypal Personality Disorder have odd beliefs, for

instance, they may believe they can read other people's thoughts, or
that that their own thoughts have been stolen from their heads.

- These odd or superstitious beliefs and fantasies are inconsistent with

cultural norms.

- Schizotypal Personality Disorder tends to be found more frequently in

families where someone has been diagnosed with Schizophrenia; a
severe mental disorder with the defining feature of psychosis (the loss
of reality testing). There is some indication that these two distinct
disorders share genetic commonalities

4) Antisocial personality disorder (ASPD or APD) is a personality

disorder characterized by a long term pattern of disregard for, or violation
of, the rights of others. A low moral sense or conscience is often apparent,
as well as a history of crime, legal problems, or impulsive and
aggressive behavior
5) Dependent personality disorder (DPD) is an anxious personality
disorder characterized by an inability to be alone. People with DPD
develop symptoms of anxiety when they're not around others. They rely on
other people for comfort, reassurance, advice, and support
6) Obsessive conpulsive personality disorder is a personality disorder that
causes a person to have an excessive perfectionism mindset and has the
disere to control all aspects of life.

32
 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 (Kaplan and Sadock, 2010).

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.

33
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. On paranoid schizophrenic patients, symptoms often look
consistent, often paranoid, patients may or may not act according to their
ideals. patients are often uncooperative, and difficult to collaborate with, and
may be aggressive, angry, or frightened, but patients rarely display
disorganization behavior.

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. This study included patients who were
admitted to a psychiatric ward and outpatients who were attending the
community mental health center. Only those patients who had living mothers
were approached and breastfeeding histories of patients and control subjects
were obtained from their mothers.

34
 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 and is the cause of the
perfectionist personality.

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 elemtary school, junior high, senior high, university :
high achieving student who always be the best ten of his class ?
Answer :
Normal, meaning there is no cognitive impairment.

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

35
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 Negative
of self care, eye contact with the Symptom
interviewer are exist.
Attitude and Not cooperative and agitative Abnormal
behaviour
Speaking Fluent verbalization Normal
Mood Hypertimic and unstable Abnormal,
Interpretation :
Mania
Affect Inappropriate Abnormal
Thought Not realistic, irrelevant, Abnormal
inchoherent., Delusion (+)
Perception Auditoric hallucination (+) Abnormal :
dissorder Illution (-) perseption
disorder
Intelligence Memory is normal, theres no Normal
amnesia
Time-place Normal Normal
orientation
Reality testing Disturbed Abnormal :
ability Psychotic
disorder
Insight First grade 36 Completely denial
of having illness
Judgement Distrubed Abnormal
b. What is the mechanism abnormal of psychiatry ?
Answer :

Genetic Stressor Anankatis

personalit
y
Disfunction/
imbalance
nurotransmitter

↑Dopaminergic
(Mesolimbic pathway),
↓Dopaminergic
(Mesocortical pathway),
↑Serotonin,
↑Norepinephrine,
↓Glutamat,
↓GABA

Negative Positive ↓
Signs Signs Cognitive
functions
Hallucinatio
n& Laughing by himself,
Timid and
Delussion Thought:
reserve, not
to go to the irrelevant,not
collage, realistic, incoheren
often spent Lack of cooperation,
his time Poor self care,
watching Poor discriminative
the judgement
television,

37
c. What is the classification of hallucination ?
Answer :
Classification of hallucination (Elvira, 2017).
a) Hypnogogic hallucinations, which are false sensory perceptions that
occur when falling asleep, are generally not classified as pathological
phenomena.
b) Hypnopompic hallucinations, which are false sensory perceptions that
occur when a person starts to wake up, are generally not classified as
pathological phenomena.
c) Auditory hallucinations, which are false perceptions of sound, usually in
the form of people's voices, although they may be in the form of other
sounds such as music, the hallucinations most often found in psychiatric
disorders.
d) Visual hallucinations, which are perceptions of erroneous deletions that
can be clear forms (people) or unclear shapes (flashes of light), often
occur in general medical disorders.
e) Hallucination of smells, which are false perceptions of smells, often
occur in general medical disorders.
f) Taste hallucinations, namely the perception of mistaken taste like
discomfort as an initial symptom of seizures, often occurs in general
medical disorders.
g) Tactile hallucinations, which are false touch perceptions such as phantom
libs (sensations of amputated limbs), or formations (sensations creeping
under the skin).
h) Somatic hallucinations, which are mistaken sensations that occur on or in
his body, more often involving internal organs.
i) Liliput hallucinations, which are false perceptions that result in smaller
visible objects.

38
d. What is the classification of scizofrenia ?
Answer :
Klasifikasi skizofrenia (Maslim & Rusdi. 2013).
1) Schizofrenia paranoid
2) Schizofrenia hebefrenik
3) Schizofrenia katatonik
4) Schizofrenia undifferentiated
5) Post-schizofrenic depression
6) Schizofrenia residual
7) Schizofrenia simplex
8) Schizofrenia lainnya
9) Schizofrenia YTT

e. What are the prodromal symptom from scizofrenia ?

Answer :
The Diagnostic and Statistical Manual (DSM)-III-R (American Psychiatric
Association 1987) 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:
a) Marked social isolation or withdrawal
b) Marked impairment in role functioning
c) Markedly peculiar behavior
d) Marked impairment in personal hygiene and grooming
e) Blunted or inappropriate affect
f) Digressive, vague, overelaborate or circumstantial speech, or poverty of
speech, or poverty of content of speech
g) Odd beliefs or magical thinking
h) Unusual perceptual experiences
i) Marked lack of initiative, interests, or energy.

39
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

40
 - 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 :
- Paranoid type schizophrenia,
- Schizoaffective type manic
- 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

41
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 : Cancalled marriage
Axis V : GAF Scale 20-11

11. How is the case management?

Answer :
1) Pharmacotherapy:
a. 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
b. Mood stabilizer : Litium 800 mg at night.
2) Psychotherapy
Psychosocial Therapy
1. Behavioral Therapy
Behavioral therapy uses economic rewards and social skills training to
improve social abilities, self-fulfillment, practical training, and
interpersonal communication.

42
 2. Family-oriented therapy
This therapy is very useful because schizophrenia patients are often
discharged in a state of partial remission, where schizophrenic patients
often benefit from short but intensive (daily) family therapy.
3. Group therapy
Group therapy for schizophrenia usually focuses on plans, problems and
relationships in real life. Groups may be behaviorally oriented,
psychodynamically oriented or insightful, or supportive. Group therapy is
effective in reducing social isolation, increasing a sense of unity, and
increasing reality tests for schizophrenia patients.
4. Individual psychotherapy
The best research on the effects of individual psychotherapy in the
treatment of schizophrenia has provided data that therapy will help and
add to the effects of pharmacological therapy. An important concept in
psychotherapy for schizophrenic patients is the development of a
therapeutic relationship experienced by patients.

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
- Able to make a clinical diagnosis and provide preliminary therapy in non-
emergency situations.

43
 - Able to determine the most appropriate referral for patients. Medical
graduates are also able to follow up after returning from a referral.

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).

2.6. Conclusion
Nassar, 30 years old experience auditoric hallucination, dellusion, unhedonia, and
withdrawing from the society due to paranoid schizophrenia with anankastic
personality.

44
2.7. Conceptual Framework

F. Psycologi F. Social F. Biology

Anankastic Cancelled Genetik

personality trait marriage
Parenting disorder

Disturbance in
the
hypothalamus

Stimulate adrenal
cortex

Neurotransmitter
imbalance

Dopamine ↑Serotonin, Dopamine

increases in ↑Norepineph decrease in
mesolimbic rine, mesocortical
↓Glutamat,
↓GABA
Positive Negative
Symptoms Symptoms

Hallucination
Delusion Unhedonia
Withdrawal

PARANOID SCHIZOPHRENIA

45
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