TUTORIAL REPORT BLOK XIV

SCENARIO A

GROUP 1
Supervisior : dr. Putri Rizki Amalia Badri, M.KM
Member’s Name :

Salsabilla 702020007
Ridho Stiawan 702020016
Muhammad Imam Faris Aqil 702020032
Vicky Kelvino 702020048
Fierzi Ratu Amalia 702020051
Berliana Noviandini 702020064
Amirah Jasmine Rabitta 702020081
Gina Tul Farhah 702020094
Shafira Izzatunnisa 702020097
Rizki Amanah 702020104
Iktia Ica Ramafachrani 702020119

FACULTY OF MEDICINE
MUHAMMADIYAH PALEMBANG UNIVERSITY
2022/2023
 FOREWORD

Bismillahirrahmaanirrahim.
Assalamu’alaikum wr. wb.
Praise our thanks to Allah SWT for all his grace and grace so that we can finish
the Tutorial Scenario B Block XIV. Sholawat as greetings always pour out to our lord,
the great prophet Muhammad and his family, friends and followers until the end of
the age. We recognize that this tutorial report is far from perfect therefore we expect
constructive criticism and suggestions, in order to refine the next tasks. In completing
this tutorial task, we have much help, guidance and advice. On this occasion express
the respect and gratitude to:
1. Allah SWT, who has given life with the coolness of faith.
2. dr. Putri Rizki Amalia Badri, M.KM as our tutor.
3. All Members and related parties in the production of this report.
May Allah SWT give a reward for all the charity given to all those who have
supported us and hopefully this tutorial report useful for us and the development of
science. Hopefully we are always in the protection of Allah SWT. Aamiin Ya
Rabbal’alamiin.
Wassalamu’alaikum wr. wb.

Palembang, 23 September 2022

Author

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 TABLE OF CONTENTS

FOREWORD ............................................................................................................... 1
TABLE OF CONTENTS ............................................................................................ 2
CHAPTER I ................................................................................................................. 1
INTRODUCTION ....................................................................................................... 1
1.1. Background ...................................................................................................... 1
1.2. Purpose and Objectives .................................................................................... 1
CHAPTER II ................................................................................................................2
DISCUSSION ............................................................................................................... 2
2.1. Tutorial Data .................................................................................................... 2
2.2. Scenario ............................................................................................................2
2.3. Clarification Of Terms ..................................................................................... 3
2.4. Identifcation of Problem .................................................................................. 3
2.5. Problem of Priority ...........................................................................................4
2.6. Problem of Analysis .........................................................................................5
2.7. Hypothesis ......................................................................................................32
2.8. Conceptual Framework .................................................................................. 33
BIBLIOGRAPHY ......................................................................................................34

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 CHAPTER I
INTRODUCTION
1.1. Background
One of the learning strategies for the Competency-Based Curriculum (CBC)
system is a Tutorial. Tutorial is an implementation of the Problem Based
Learning (PBL) method. In the tutorial, students are divided into small groups
and each group is guided by a tutor / lecturer as a facilitator to solve existing
cases.
In block XIV, namely the mental health and noble function, a scenario case
study tutorial entitled "Black Magic" is carried out in order to train

1.2. Purpose and Objectives

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

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 CHAPTER II
DISCUSSION
2.1. Tutorial Data
Tutor : dr. Putri Rizki Amalia Badri, M.KM
Moderator : Muhammad Imam Faris Aqil
Desk Secretary : Gina Tul Farhah
Secretary Board : Berliana Noviandini
Tutorial Time : Tuesday, September 20th 2022

2.2. Scenario
Mr. M, 20 years old, unmarried, doesn’t work, was taken to the Prof Ernaldi
Bahar Hospital Emergency with a complaint suspicious. According to his Brother,
about 2 years ago, after Mr. M didn't pass entrance the army exam, the patient
worked in Kalimantan. The patient began often to learn black magic, the patient
told his brother its to open the eyes of heart and mind so he could be smart. Mr. M
starts not coming to work with the reason that many people don’t like him,
because he feels since learning the black magic that he has become smarter.
Patient also often say, when he meets a bad person his eyes, heart, and mind
are closed again. Patient is often seen not sleeping and seen restless. Then the
patient was taken for treatment to a public hospital in Kalimantan and was given 3
kinds of drugs, white, pink and orange. Patient taking medication for 1 month and
get experienced improvement so they felt didn’t need to take medication again.
Patient can return to work but often seen saving amulets.
About 3 months ago, the patient was dismissed by his company and returned
to Palembang. The Patient was dismissed because he often felt suspicious of his
co-workers. According to his Brother, the patient often said that someone wanted
to harm him, that creature often appears in his room and wants to take the
patient's intelligence. The patient knows it because he has gone to supernatural
medicine. Patient almost every night going to the temple to cleanse from these
creatures.
Premorbid history: Patient is know as a quite child who is more often in the
room, prone to rejection, tends to blame others when his make mistakes.

2
 Autoanamnesis
At the time of the interview, Mr. M still recognizes his brother and knows
that he is in the hospital. When asked, Mr. M answers not in accordance with the
question and sometimes difficult to understand. Occasionally looking at the walls
and roofs while saying "be careful there are creatures that will take the doctor's
intelligence”.

Physical Examination:
Compos mentis; Blood pressure 110/80 mm Hg; Pulse 84 ›/menit; RR 24
x/menit; Temp. 36,9° C. Body Weight 60 Kg, Body Height 170 cm

2.3. Clarification Of Terms

1. Suspicious : having or causing suspicion
2. Premorbid : happen before development disease
3. Autoanamnesis : story of patient disease especially best on patient
memory (Dorland)
4. Supernatural : seeming magical
5. Amulets : objects worm to protect you from evil
6. Prone : lying face down
7. Medicine : give any medicine (dorland 30 edition)
8. Harm : damage, injury
9. Creatures : living animal person (oxford dictionary)
10. Restless : relaxing and peacefully

2.4. Identifcation of Problem

1. Mr. M, 20 years old, unmarried, doesn’t work, was taken to the Prof Ernaldi
Bahar Hospital Emergency with a complaint suspicious. According to his Brother,
about 2 years ago, after Mr. M didn't pass entrance the army exam, the patient
worked in Kalimantan. The patient began often to learn black magic, the patient
told his brother its to open the eyes of heart and mind so he could be smart. Mr.
M starts not coming to work with the reason that many people don’t like him,
because he feels since learning the black magic that he has become smarter.
2. Patient also often say, when he meets a bad person his eyes, heart, and mind are
closed again. Patient is often seen not sleeping and seen restless.

3
3. Then the patient was taken for treatment to a public hospital in Kalimantan and
was given 3 kinds of drugs, white, pink and orange. Patient taking medication for
1 month and get experienced improvement so they felt didn’t need to take
medication again. Patient can return to work but often seen saving amulets.
4. About 3 months ago, the patient was dismissed by his company and returned to
Palembang. The Patient was dismissed because he often felt suspicious of his co-
workers. According to his Brother, the patient often said that someone wanted to
harm him, that creature often appears in his room and wants to take the patient's
intelligence. The patient knows it because he has gone to supernatural medicine.
Patient almost every night going to the temple to cleanse from these creatures.
5. Premorbid history: Patient is know as a quite child who is more often in the room,
prone to rejection, tends to blame others when his make mistakes.
6. Autoanamnesis
At the time of the interview, Mr. M still recognizes his brother and knows that he
is in the hospital. When asked, Mr. M answers not in accordance with the
question and sometimes difficult to understand. Occasionally looking at the walls
and roofs while saying "be careful there are creatures that will take the doctor's
intelligence”.
7. Physical Examination:
Compos mentis; Blood pressure 110/80 mmHg; Pulse 84x/menit; RR 24 x/menit;
Temp. 36,9° C. Body Weight 60 Kg, Body Height 170 cm

2.5. Problem of Priority

Identification No. 1 : Mr. M, 20 years old, unmarried, doesn’t work, was
taken to the Prof Ernaldi Bahar Hospital Emergency with a complaint suspicious.
According to his Brother, about 2 years ago, after Mr. M didn't pass entrance the
army exam, the patient worked in Kalimantan. The patient began often to learn
black magic, the patient told his brother its to open the eyes of heart and mind so
he could be smart. Mr. M starts not coming to work with the reason that many
people don’t like him, because he feels since learning the black magic that he has
become smarter.
Reason : Because he learned black magic and he had delusions (waham) and
needed further treatment.

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2.6. Problem of Analysis
1. Mr. M, 20 years old, unmarried, doesn’t work, was taken to the Prof Ernaldi
Bahar Hospital Emergency with a complaint suspicious. According to his
Brother, about 2 years ago, after Mr. M didn't pass entrance the army exam,
the patient worked in Kalimantan. The patient began often to learn black
magic, the patient told his brother its to open the eyes of heart and mind so he
could be smart. Mr. M starts not coming to work with the reason that many
people don’t like him, because he feels since learning the black magic that he
has become smarter.
a. What are the neuroanatomy for this case?
- Lymbic system
Hypothalamus
The hypothalamus has many nuclear regions, which are classified
according to their location into groups of anterior, middle, and posterior
nuclei:
1. The chiasmatic nucleus group (anterior nucleus group) includes the
suprachiasmatic nucleus (central triggers of circadian rhythm, wake-
sleep cycle, body temperature, blood pressure), paraventricular and
supraopticus nuclei (production of ADH and oxytocin hormones),
preoptic nuclei (blood pressure regulation, body temperature, sexual
behavior, menstrual cycle)
2. the intermediate nuclear group (middle nuclear group) includes the
tuberal, dorsomedialis, ventromedial, and arcuate nuclei.
3. The posterior nuclear group includes the corpora mamillary nuclei in
the corpora mamillaria, because afferent fibers from the fornix and
efferent fibers to the thalamus are integrated in the limbic system. This
structure affects sexual function and plays an important role in
activities related to memory and emotion (Paulsen, F & Waschke, J,
2018).

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 Figure 1. Limbic System
(Paulsen, F & Waschke, J, 2018).

- Cortex cerebri
Functional areas of the cerebral hemispheres of the cortex;
The homunculus (mannequin) roughly reflects the somatotopic map of the
primary somatosensory cortex. The primary and secondary auditory
cortex and WERNICKE center extend on the surface within the superior
border of the temporal lobe (Paulsen, F & Waschke, J, 2018).

Figure 2. cerebral cortex

(Paulsen, F & Waschke, J, 2018).

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b. What are the physiology for this case?
 Limbic System
The limbic system is not a separate structure but an interrelated
functional system consisting of a ring of forebrain structures that surround
the brainstem and are interconnected through complex neuronal pathways.
This structure includes parts of: the lobes of the cerebral cortex
(especially the limbic association cortex), the basal nucleus, the thalamus,
and the hypothalamus. This complex interactive fabric deals with
emotions, survival and patterns of sociosexual behavior, motivation and
learning.
Hypothalamus; It is an integrating center for many homeostatic
functions and serves as an important link between the autonomic nervous
system and the endocrine system. Specifically, the hypothalamus (1)
controls body temperature, (2) controls thirst and urine output, (3)
controls food intake, (4) controls anterior pituitary hormone secretion, (5)
produces posterior pituitary hormones, (6) controls contractions. uterus
and milk ejection, (7) coordination center of the major autonomic nervous
system, and (8) play a role in emotional and behavioral patterns and
sleep-wake cycles.

- The limbic system plays an important role in emotions

The concept of emotion includes subjective emotional feelings and
moods (eg anger, fear, sadness, and joy) as well as actual physical
responses associated with these feelings. These responses include specific
behavioral patterns (e.g., preparing to attack or defend when threatened
by an enemy) and observable emotional expressions (e.g. laughing, crying,
or blushing). Emotions are highly objective and can differ between
individuals in response to identical circumstances. The limbic system
plays an important role in all aspects of emotion. Stimulation of specific
regions in the human limbic system during brain surgery produces a
variety of subtle subjective sensations that patients describe as pleasure,
satisfaction, or pleasure in one region and disappointment, fear, or anxiety
in another. For example, the amygdala is critical for processing inputs
that produce sensations of fear and anxiety. In humans and to an unknown

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 extent in other species, the higher levels of the cortex are also crucial for
awareness of emotional feelings (Sherwood, L. 2019).
 Cerebral cortex
The role of Broca's area and wernicke area. Broca’s area, which
controls speech, is located in the left frontal lobe adjacent to the motor
cortex area that controls the muscles for articulation. Wernicke's area,
located in the left cortex at the junction of the parietal, temporal, and
occipital lobes, is concerned with language comprehension. This section
plays an important role in understanding spoken and written language. In
addition, Wernicke is responsible for formulating a coherent pattern of
speech that is transmitted through the fiber bundles to Broca's area, which
ultimately controls the articulation of speech (Sherwood, L. 2019).

c. What is the meaning Mr. M, 20 years old, unmarried, doesn’t work, was
taken to the Prof Ernaldi Bahar Hospital Emergency with a complaint
suspicious?
Young age of onset unmarried leads to poor prognosis in patients
whose chief complaint is suspicious signs of delusions leading to
schizophrenia Schizophrenia is a complex, chronic mental health disorder
characterized by an array of symptoms, including delusions,
hallucinations,disorganized speech or behavior, and impaired cognitive
ability. The early onset of the disease, along with its chronic course, make
it a disabling disorder for many patients and their families. In addition,
relapse may occur because of positive symptoms, such as suspiciousness,
delusions, and hallucinations.The inherent heterogeneity of schizophrenia
has resulted in a lack of consensus regarding the disorder’s diagnostic
criteria, etiology, and pathophysiology (Patel Krishna R, 2014).

d. What is the meaning according to his Brother, about 2 years ago, after Mr.
M didn't pass entrance the army exam, the patient worked in Kalimantan?
The meaning is that didn’t pass entrance the army exam is a
psychosocial stressors about educational problem. This condition is one of
stressful life event due to failure of a person in fulfilling a demands will

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 lead to the occurrence of personality lapses which is the beginning of the
occurrence of mental disorders (Rotenberg et al. 2017).

e. What is the meaning The patient began often to learn black magic, the
patient told his brother its to open the eyes of heart and mind so he could
be smart. Mr. M starts not coming to work with the reason that many
people don’t like him, because he feels since learning the black magic that
he has become smarter?
It means that Mr., M has paranoid delusions which include delusions
of pursuit and delusions of grandeur. In this case he thought that many
other people disliked him so that suspicion arose, and he overestimated
himself by feeling smarter since learning black magic (Kaplan & Sadock.
2010).
Mr. M experiences delusion. If according to PPDGJ III this leads to
the diagnostic criteria of schizofrenia hebefrenik which is one of the
positive symptoms of schizophrenia (Maslim, 2019).

f. What is the corelation between main complaint and didn't pass entrance
the army exam?
Didn’t pass entrance the army exam is precipitating factor for mental
disorder. There are two factor that can cause mental disorder,
predisposing and precipitating. the example of predisposing factor is
genetic, premorbid history. And the example of precipitating factor is
divorced, withdrawal drug (Mawaddah dkk., 2020)
Not passing the military exam is a risk factor for major complaints.
Social defeat in the form of discrimination, human rights violations,
poverty, and exposure to other environmental risks can lead to psychotic
disorders due to stressors. The more severe the social stressor experienced
by a person, the greater the likelihood of developing a psychotic disorder
(Davis J, et al. 2016).

g. What is relation between gender, age, marital status and occupation in ths
case?

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 Based on the age and gender, it is most occur in late adolescence or
young adulthood. Onset occurs earlier in men than women. The peak age
of onset is 8 to 25 years for men and 25 to 35 years for women. Based
studies indicate that men are more likely to experience impairment due to
negative symptoms than women and that women are more likely to have
better social functioning than men before the onset of the disease. In
general, the outcome of female schizophrenic patients is better than that
of male schizophrenic patients (Sadock, B.J., Sadock, V.A. 2022).
According to research by Agung Wahyudi and Arulita Ika Fibriana
(2016), there is a relationship between employment status and the
incidence of schizophrenia which has an OR value of 3.385 (95% CI
1.180-9.708). Based on status unmarried, a person who not married has a
higher risk suffer from schizophrenia than people already married because
marital status is deemed necessary to exchange ego to achieve peace,
mindfulness and love are the thing very fundamental to achieve a a
meaningful and fulfilling life. Marital status is a risk factor associated
with the occurrence of schizophrenia because one of the causes of
psychosocial stressors experienced by some people is caused by marital
status, those who are not married are at higher risk of developing
schizophrenia than those who are married with an OR value of 4.747
(95% CI 1.575- 14,312) (Wahyudi Agung, 2016).

h. What are etiology of the patient complaint in this case?

According to PPDGJ III, not much is known about the causes of
schizophrenia (Maslim, R. 2019). According to the Journal of Mental
Nursing at the University of Muhammadiyah Semarang, there are several
factors that can affect the patient's quality of life schizophrenia in which
these factors are shared on eight factors that can affect the patient's
quality of life schizophrenia, namely physical health factors, social factors,
emotional factors and factors activity (Puspita, G.W & Afconneri, Y.
2020).
One explanation for the development of schizophrenia is that the
disorder begins in utero. Obstetric complications, including bleeding
during pregnancy, gestational diabetes, emergency cesarean section,

10
 asphyxia, and low birth weight, have been associated with schizophrenia
later in life. Fetal disturbances during the second trimester—a key stage
in fetal neurodevelopment—have been of particular interest to researchers.
Infections and excess stress levels during this period have been linked to a
doubling of the ris.k of offspring developing schizophrenia. ( Patel
Krishna R, 2014)
Scientific evidence supports the idea that genetic factors play an
important role in the causation of schizophrenia; studies have shown that
the risk of illness is approximately 10% for a first-degree relative and 3%
for a second-degree relative. In the case of monozygotic twins, the risk of
one twin having schizophrenia is 48% if the other has the disorder,
whereas the risk is 12% to 14% in dizygotic twins. If both parents have
schizophrenia, the risk that they will produce a child with schizophrenia is
approximately 40%. ( Patel Krishna R, 2014)
Studies of adopted children have been conducted to determine
whether the risk of schizophrenia comes from the biological parents or
from the environment in which the child is raised. These investigations
have tended to show that changes in the environment do not affect the
risk of developing schizophrenia in children born to biological parents
with the illness. A genetic basis for schizophrenia is further supported by
findings that siblings with schizophrenia often experience onset of the
disorder at the same age. ( Patel Krishna R, 2014).
Environmental and social factors may also play a role in the
development of schizophrenia, especially in individuals who are
vulnerable to the disorder. environmental stressors linked to
schizophrenia include childhood trauma, minority ethnicity, in an urban
area, and social isolation. In addition, social stressors, such as
discrimination or economic adversity, may predispose individuals toward
delusional or paranoid thinking. ( Patel Krishna R, 2014)..
i. What is the phatophysiology of the patient complaint in this case?
Risk factor (didn’t enterance army, genetic)  spiny dendrite
atrophy on cortex prefrontal  transmission glutamate impaired 
glutamate decreased  activation glutamate receptor decreased 

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 produced GABA decreased  dopamine increased  dpaminergik
hyperactivity  delusion (Silbernagl, 2018)

2. Patient also often say, when he meets a bad person his eyes, heart, and mind
are closed again. Patient is often seen not sleeping and seen restless.
a. What is the meaning Patient also often say, when he meets a bad person
his eyes, heart, and mind are closed again. Patient is often seen not
sleeping and seen restless?
The meaning of Patient also often say, when he meets a bad person
his eyes, heart, and mind are closed again is that Mr.M has Bizarre
delusion. Bizarre delusions is false and strange beliefs, very unreasonable
(Sadock, B.J., Sadock, V.A. 2022).
The meaning of Patient not sleeping and seen restless are negative
symptom experienced by patients (Elvira S & Hadisukanto G. 2021).

b. How the pathophysiology seen not sleeping and seen restless?

Environmental stressor and education stressor  stimulates the
hypothalamus torelease hormones in the adrenal medulla → increases the
biosynthesis of dopamine, epinephrine, and norepinephrine → increased
alertness → not sleeping seen restles (Grace, 2016).
Neurobiological abnormalities underlie some of the circadian sleep-
wake problems in Skizofrenia (SZ). The suprachiasmatic nucleus (SCN)
is the master circadian pacemaker, whose role consists in orchestrating
levels of hormones like melatonin, cortisol and prolactin, and core body
temperatures according to a fixed cycle that is synchronised by
environmental cues. As noted above, investigations of circadian rhythm
chronobiologic parameters in SZ have identified dysregulation of the
SCN, including abnormal 24-hr rhythms (phase advance) of melatonin
and serotonin, body temperature, cortisol, and prolactin e.g. In addition to
the role of serotonin dysfunctions, deficits of the inhibitory
neurotransmitter gamma amino butyric acid (GABA) may play a role in
SZ sleep dysfunctions. GABAergic alterations are well documented in SZ,
and some researchers have pointed to animal and human studies linking

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 GABA to sleep architecture and homeostatis, suggesting a potential role
of GABA receptors in SZ sleep abnormalities (Grace, 2016).

c. What are the impact not sleeping and seen restless?

Some people are normally short sleepers and only need less than 6
hours of sleep each night to function adequately. A long-sleeper is a
person who sleeps more than 9 hours each night to function adequately.
Long sleepers have more REM periods and more REM in each period
(known as REM density) than short sleepers (Kaplan, HI, Sadock, BJ
2017).
Prolonged periods of sleep deprivation sometimes lead to ego chaos,
hallucinations, and delusions. Depriving people of sleep by waking them
early in the rapid eye movement (REM) cycle causes an increase in the
number of REM periods and the amount of REM sleep (rebound increase)
when they are allowed to sleep undisturbed. Patients who are deprived of
REM sleep may exhibit irritability and lethargy. In studies using mice,
sleep deprivation causes a syndrome that includes a weak appearance,
skin lesions, increased food intake, weight loss, increased energy
consumption, decreased body temperature, and death (Kaplan, HI, Sadock,
BJ 2017).

d. What are the classification of sleep disorder?

 F51.0 insomnia non-organic
 F51.1 hypersomia non-organic
 F51.2 non-organic disturbance of sleep-wake schedule
 F51.3 Somnambulism (sleep walking)
 F51.4 Night terrors
 F61.5 Nightmares
 F51.8 Other non-organic sleep disorder
 F51.9 non-organic sleep disorder not classified (Maslim, 2019)

3. Then the patient was taken for treatment to a public hospital in Kalimantan
and was given 3 kinds of drugs, white, pink and orange. Patient taking
medication for 1 month and get experienced improvement so they felt dindnt

13
need to take medication again. Patient can return to work but often seen saving
amulets.
a. What is the meaning Then the patient was taken for treatment to a public
hospital in Kalimantan and was given 3 kinds of drugs, white, pink and
orange?
Drugs that are given anti-psychotic drugs with drugs colored orange
(Chlorpromazine 100mg>APG 1 or Risperidone 2mg APG>2), pink
(Haloperidol 5mg) and anti-anxiety drugs benzodiazepine class
(Diazepam 2mg).

b. What are the pharmacokinetics and pharmakodynamics for this case?

1st generation antipsychotics (APG-1) Phenothiazines,
thioxanthines, butyrophenones, thioxantines.
Pharmacokinetics
 Absorption:
- Peroral/parenteral -drug in liquid form is absorbed more rapidly than
tablets
- Peak plasma drug concentration 1-4 hours after oral administration and
30-60 minutes after intramuscular administration.
 Distribution:
Decrease in plasma concentration occurs due to distribution of the
drug to various parts of the body. Because antipsychotic drugs are
lipophilic, they tend to accumulate in adipose tissue, lungs, and brain.
 Metabolism:
Most of the metabolism of APG-I is carried out by the liver and occurs
via conjugation (with glucurinic acid), hydroxylation, oxidation,
demethylation, and sulfoxide formation.
 Excretion: Renal

Pharmacodynamics
The drug APG-I acts on the neurotransmitter D2 receptors by
decreasing dopamine activity.

Antipsychotics generation II (APG II)

Pharmacokinetics of clozapine

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  Absorption: Clozapine is available only as an oral preparation with
peak plasma concentrations achieved after two hours of oral
administration.
 Distribution: The volume of distribution of clozapine is lower.
 Metabolism: mainly in the liver and gastrointestinal tract. Absolute
bioavailability (percentage of clozapine reaching the systemic
circulation unchanged) after oral administration ranged from 27% to
47%. There are two forms of metabolites (after demethylation and
oxidation) namely N-demethyl and N Oxide. Second
 Excretion: These metabolites are excreted rapidly in urine and feces.

Pharmacodynamics
Its affinity for D is low while for 5-HT, it is high. This is what causes
the low extrapyramidal side effects.
(Elvira S & Hadisukanto G. 2021)

c. What is the meaning Patient taking medication for 1 month and get
experienced improvement so they felt dindnt need to take medication
again. Patient can return to work but often seen saving amulets?
If the patient is discontinued on the basis of feeling better, it can lead
to relapse. Recurrence in one year after being diagnosed with
schizophrenia is experienced by 60-70% of patients who do not receive
medication therapy. The phenomenon of recurrence is mostly caused by
drug withdrawal. In this condition, schizophrenia can be said to be
chronic by knowing the causes of patient non-compliance with drug
therapy which includes patients feeling bored taking medication, lack of
understanding of patients about treatment goals, reduced symptoms, did
not understand the instructions for using drugs, inaccurate dosages in
taking drugs, unpleasant side effects, and high drug prices (Maslim,
2019).
This means that the patient experiences delusions (delusions), such
as delusions of influence (delusions about himself being influenced by
certain external forces). or delusion of paranoia which is characterized by
the appearance of excessive suspicion and fear. by carrying the amulet he

15
 feels that he is safe and someone is protecting him because he suspects
that his co-workers don't like him and that someone wants to hurt him so
that the presence of the amulet can help him and the patient can return to
work. (Hendarsyah, 2016).
According to PPDGJ III In schizophrenia hebephrenic there is a
superficial and contrived preoccupation about religion,philosophy,etc,and
make people more difficult to understand the patient. So this leads to the
diagnostic criteria of schizophrenia hebefrenik which is one of the
positive symptoms of schizophrenia (Maslim, 2019).

d. What are the phases of treatment in this case?

1) Acute phase, when patients show psychotic symptoms such as
delusions, hallucinations, and disorganized thinking
2) Continuation treatment phase, this phase begins once the acute
symptoms reduce in severity and conventionally lasts for about 6-12
month. Medication need to continue preferably at the same dose for the
next 6-12 months.
3) Maintenance or stable phase, during this phase of illness, symptoms
are stable and usually less severe than in the acute stage. Negative
symptoms may predominate and deficits in social and occupational
functioning become more apparent. During this phase, follow ups can
be scheduled pnce every 2-3 months (Grover dkk., 2017)

4. About 3 months ago, the patient was dismissed by his company and returned
to Palembang. The Patient was dismissed because he often felt suspicious of
his co-workers. According to his Brother, the patient often said that someone
wanted to harm him, that creature often appears in his room and wants to take
the patient's intelligence. The patient knows it because he has gone to
supernatural medicine. Patient almost every night going to the tample to
cleanse from these creatures.
a. What is the meaning about 3 months ago, the patient was dismissed by his
company and returned to Palembang. The Patient was dismissed because
he often felt suspicious of his co-workers?

16
 Mr. M experienced disturbances in work and social functions due to
bizarre delusions of mystical things (Elvira S & Hadisukanto G. 2021)

b. What are the classification of delusions and hallucination? (gina, ica, faris)
- Delusions: false beliefs, based on false conclusions about external
reality, inconsistent with the patient's intellectual and cultural
background; cannot be corrected by reasoning.
a) Bizarre delusions: false and strange beliefs, very unreasonable. (for
example, an intruder from outer space has implanted electrodes
into his brain).
b) Systematic delusions: false beliefs or beliefs held together by a
single event or theme (for example, a person feels like he is being
chased by the CIA, FBI, or mafia).
c) Mood-congruent delusions delusions whose content corresponds to
mood (for example, a depressed patient who believes he or she is
responsible for the destruction of the world).
d) Incongruent delusions: delusions with content inconsistent with
ntood or neutral to ntood (eg, a depressed patient who has
delusions of thought control or thought content broadcasting).
e) Nihilistic delusions: false feelings that oneself, others, and the
world do not exist or will experience an end.
f) Poverty delusion: a false belief in a person that he is bankrupt or
will lose all his possessions.
g) Sornatic delusions: false beliefs that involve bodily functions (for
example, beliefs that the brain is rotting or melting).
h) Paranoid delusions: these include delusions of pursuit and
delusions of reference, control, and grandiosity (as distinct from
paranoid ideas, i.e. suspicion with a lower than proportionate
delusion).
i. Delusions of bullying: false belief in someone who feels they are
being harassed, cheated, or being chased; often found in patients
with legal cases who have a pathological tendency to take legal
action because of an imaginary wrongdoing.

17
 ii. Delusions of grandeur: a person's concept of self-importance,
power or identity is exaggerated.
iii. Delusions of ru.iukan: a false belief in a person that the
behavior of others is directed at him: that a person, object, or
other person has a particular and extraordinary importance,
usually in a negative connotation; stems from the idea of
reluctance, which is when a person falsely perceives that other
people are talking about him (for example, the belief that
people on TV and radio talk to or about him).
i) Delusions flare up: feelings of remorse and misplaced guilt.
j) Delusion of control: the false feeling that one's desires, thoughts,
or feelings are controlled by external forces.
k) Withdrawal of mind: the delusion that one's thoughts are removed
from oneself by another person or force.
l) Thought insertion: rvaham that a thought is implanted into one's
brain by another person or force.
m) Thought broadcasting: the delusion that one person's thoughts can
be heard by another. it was as if the thought was broadcast in the
air.
n) Mind control: understanding that one's mind is controlled by
another person or force.
o) Delusions of infidelity (jealousy delusions): a false belief that
stems from a person's pathological jealousy that his lover is
unfaithful.
p) Erotomania: a delusional belief, found more often in women than
men, that a person is in love with him or her (also known as the
Cldrambault-Kandins complex).
q) Pseudologia fantastika: a form of lying when a person seems to
believe that his fantasies are real and happen to him; associated
with Munchausen syndrome, repeatedly faking the disease.

- Hallucinations: false sensory perceptions that are not associated with a

real external stimulus; there may be a delusional interpretation of the
hallucinatory experience but it may not.

18
a) Hypnagogic hallucinations: false perceptions that occur when
falling asleep; generally regarded as a non-pathological
phenomenon.
b) Hypnopompic hallucinations: false perceptions that occur upon
awakening from sleep; usually considered non-pathological.
c) Auditory hallucinations: false perceptions of sound, usually in the
form of voices but can also be in the form of other sounds, for
example music, are the most common hallucinations found in
psychiatric disorders.
d) Visual hallucinations: false perceptions involving seeing both a
shaped image (eg, a person) and an amorphous image (eg a flash of
light); most often found in various medical disorders.
e) Olactoric hallucinations: false perception of smell; most often seen
in neurological disorders.
f) Gustatory hallucinations: false perception of taste, eg unpleasant
taste, caused by uncinate spasms; most common in medical
disorders.
g) Tactile (haptic) hallucinations: false perception of touch or surface
sensations, for example in a climatically amputated extremity
(phantont/irzb); the sensation of crawling on or in the cracks (orm
Ikrsi).
h) Somatic flalucination: false sensation of something happening to or
directed at the body, most often originating from the viscera
(called hcrl us i nas i senes tes ik).
i) Illusional illusions: false perception that the size of the object
appears to be shrinking (called nicropsia).
j) Nood-congruent hallucinations. hallucinations whose content is
consistent with a depressive or manic mood (for example, a
depressed patient hears voices telling him he is a bad person; a
manic patient hears a voice that says he is valuable, powerful, and
highly knowledgeable).
k) Nood-incongruent hallucinations: hallucinations whose content is
inconsistent with a depressive or manic mood (eg, in depression,
hallucinations do not involve themes such as guilt, deserved

19
 punishment, or feelings of inferiority); in mania, hallucinations do
not involve themes such as self-esteem and high power).
l) Hallucinosis: hallucinations, constellations, most often auditory.
due to chronic alcohol abuse and those that occur in clear
consciousness, in contrast to clelirium tremens, namely
hallucinations that occur in foggy consciousness.
m) Synesthesia: sensations or hallucinations elicited by other
sensations (for example, auditory sensations that accompany or
trigger visual sensations, sounds perceived as seen or visual events
perceived as audible).
(Kaplan & Sadock. 2010).

c. What is the meaning according to his Brother, the patient often said that
someone wanted to harm him, that creature often appears in his room and
wants to take the patient's intelligence. The patient knows it because he
has gone to supernatural medicine. Patient almost every night going to the
tample to cleanse from these creatures?
The meaning of "the patient often says that someone wants to hurt
him" is that the patient has delusions of being chased because he feels he
will be attacked. The meaning of "the creature often appears in his room
and wants to take the patient's intelligence" is that the patient is
experiencing visual hallucinations. So that the patient experiences
delusions and hallucinations which are characteristic of schizophrenia
(Kaplan, HI, Sadock, BJ 2017).

d. How to check the GAF scale in the case?

The GAF scale has a range of 0-100, which is each specific range
group that shows symptoms or what happens to an individual or group.
a) 100–91: Functioning optimally in a wide field, the problem of living
well because of his positive self-quality. There are no symptoms.
b) 90–81: (There are few symptoms, e.g., a little anxiety ahead of the
exam), functioning well in all areas of life, interested in & involved in
various activities, socially effective, generally satisfied with his life,

20
 problems are nothing more than ordinary problems in everyday life
(e.g., arguments with family members).
c) 80–71: (If there are symptoms that usually arise due to psychosocial
stressors, for example: difficulty concentrating after arguments in the
family), there are few distractions in social life, work or school (e.g.,
sometimes late to collect schoolwork)
d) 70-61: (Some mild & persistent symptoms, e.g., sadness and mild
insomnia) OR slight difficulties in social life, work or school (e.g.,
sometimes lying, stealing at home) but function in general quite well,
have a fairly meaningful interpersonal relationship.
e) 60–51: (Some symptoms in the mid, flat effects and talk, sometimes
panic attacks) OR impaired functioning at moderate levels in social life,
work or school (e.g., not having friends, losing work).
f) 50-41: (Serious symptoms, such as suicidal ideation, obsessive
behavior strong enough, often shoplifting) OR a serious enough
disruption to the functioning of social life, work, school, for example:
having no friends, losing a job).
g) 40–31: (Some disabilities in relation to reality &communication,
severe disabilities in some functions, for example: illogical,
incomprehensible/irrelevant, aloof, rejecting family, unable to work)
h) 30–21: Severe disability in communication &value power, unable to
function in almost any field
i) 20–11: Danger of harming oneself/threatening and hurting others
j) 10–1: persistently and more seriously endangering himself and others
(e.g. repeated acts of violence)
k) 0: Inadequate information
(Maslim, 2019).

5. Premorbid history: Patient is know as a quite child who is more often in the
room, prone to rejection, tends to blame others when his make mistakes.
a. What is the interpretation of premorbid history?
The interpretation is that mr. m has schizophrenia hebefrenik which
is characterized by he is a quite child who is more often in the room or
happy to be alone, prone to rejection and tends to blame other when his

21
 make mistakes. The prognosis in schizophrenics who have be
prepsychotic personalities, personality disorders, and persistent
personality traits is poor (Maslim, 2019).
Schizophrenia in childhood is a rare and severe form of
schizophrenia, usually appearing before 12 years of age (but not less than
5 years of age), is chronic detereorativewith a high likelihood of relapse.
Only about 12% experience complete remission (Maudsley), the rest
experience partial remission or even persist into adulthood with negative
symptoms that remain prominent. If there are psychotic symptoms that
persist for more than 6 months, the possibility of complete remission is
only about 15%, but if psychotic symptoms only appear for less than 3
months, the possibility of complete remission is greate (Widyawati, I.
2021).

b. What are the type of personality disorder?

1) Group A
There are many similarities, and they are often found in families with
schizophrenia compared to the average population.
Included in this group are:
a) Schizotypal personality disorder
b) Paranoid personality disorder
c) Schizoid personality disorder
2) Group B
This group includes:
a) Anti-social personality disorder
b) borderline personality disorder
c) Narcissistic personality disorder
d) Histrionic personality disorder
3) Group C
This group includes:
a) Avoidant personality disorder
b) Obsessive compulsive (anankastic) personality disorder
c) Dependent personality disorder
(Elvira S & Hadisukanto G. 2021).

22
6. Autoanamnesis
At the time of the interview, Mr. M still recognizes his brother and knows that
he is in the hospital. When asked, Mr. M answers not in accordance with the
question and sometimes difficult to understand. Occasionally looking at the
walls and roofs while saying "be careful there are creatures that will take the
doctor's intelligence”
a. What are the interpretation of autoanamnesis?
Mr, M doesn't have memory problems and places orientation
because he still recognizes his brother and he still knows where he is. Mr.
M has a thought disorder in the form of incoherence. Sir, M is
experiencing visual hallucinations due to saying nonsensical things after
looking at the walls and roof which means he is seeing things that are not
really there. He also experienced thought withdrawal in which his
thoughts were taken out by something outside of him (Kaplan, HI,
Sadock, BJ 2017).

b. What are the abnormal mechanism of the autoanamnesis?

Risk factor (didn’t enterance army, genetic)  spiny dendrite
atrophy on cortex prefrontal  transmission glutamate impaired 
glutamate decreased  activation glutamate receptor decreased 
produced GABA decreased  dopamine increased  dpaminergik
hyperactivity  delusion (Silbernagl, 2018)

7. Physical Examination:
Compos mentis; Blood pressure 110/80 mmHg; Pulse 84x/menit; RR 24
x/menit; Temp. 36,9° C. Body Weight 60 Kg, Body Height 170 cm
a. What are the interpretation of physical examination (manah)
All examination is normal
Information In case Normal value interpretation
General Compos mentis Compos mentis Normal
appearance
Body weight 60 kg IMT normal: 18,5- IMT:20,76

23
 Body height 170 cm 25,0 (normal)

Blood 110/80 mmHg 90-120/60-80 Normal

pressure mmHg
Pulse 84x/menit 60-100x/menit Normal
RR 24x/menit 16-24x/menit Normal
Temp 36,9 ° C. 36,5-37,5 ° C Normal

8. Pychiatry Status
Appearance : Tall, good self-care, not cooperative,
occasionally looking at the walls and roofs
while saying “be careful there are creatures
that will take the doctor’s intelligence”,
minimal physical-eye-verbal contact.
Speaking : Verbalization is clear and fluent
Intelligence : Good memory, no amnesia, good orientation,
disturbed discriminative judgement, disturbed
discriminative insight, approriate level
intelligence, no intellectual decline.
Emotion : Mood : Disforik
Afek : Irritable
Thought : Unrealistic, sometimes irrelevant, incoherent,
grandiose delusions.
Perception : Auditory hallucinations (+), Hallucinatory
behavior (+), Illusion (-)
Reality Testing Ability (RTA) : Disturbed
Insight : First grade
a. What is the interpretation of psychiatry status?
Case Interpretation
Appearance Tall, good self-care, not - Tall, good self-care, not
cooperative, occasionally cooperative : Normal

24
 looking at the walls and - occasionally looking at
roofs while saying “be the walls and roofs while
careful there are creatures saying “be careful there
that will take the doctor’s are creatures that will take
intelligence”, minimal the doctor’s intelligence” :
physical-eye-verbal Visual hallucination
contact. - minimal physical-eye-
verbal contact :
Unconfident
Speaking Verbalization is clear and Normal
fluent
Intelligence Good memory, no - Good memory, no
amnesia, good orientation, amnesia, good orientation :
disturbed discriminative Normal
judgement, disturbed -Discriminative
discriminative insight, judgement, disturbed
approriate level discriminative insight,
intelligence, no intellectual approriate level
decline. intelligence, no intellectual
decline : Abnormal
(Schizophrenia)
Emotions Mood : Disforik - Mood : Abnormal
Afek : Irritable (unhappy)
- Afek : Abnormal (easily
offended)
Thought Unrealistic, sometimes Hebefrenic Schizophrenia
irrelevant, incoherent, (Paranoid delusions)
grandiose delusions.
Perception Auditory hallucinations Abnormal (Schizophrenia)
(+), Hallucinatory
behavior (+), Illusion (-)
Reality Testing Disturbed Schizophrenia / Psychotic
Ability (RTA) disorder

25
 Insight First grade Abnormal (Full denial)

9. How to diagnose?
Anamnesis
- Reason for treatment
- Current disturbance history
- Past history of disorders
- Personal development history
- Social background, family, education, occupation, etc

Inspection
- Physical-diagnostics
- mental state
- Laboratory
- Radiology
- Psychological evaluation
- Etc

Diagnosis
Multiaxial Diagnosis :
 Axis I:
- Clinical disorders
- Other conditions that are the focus of clinical attention
 Axis II
- personality disorder
- Mental retardation
 Axis III
- General Medical Conditions
 Axis IV
- Psychosocial and environmental problems
 Axis V
- Function assessment globally

26
Schizophrenia diagnostic guidelines
- There must be at least one of the following symptoms that is very pronounced
(and usually two or more if they are less acute or less pronounced):
(a)- “thought echo”: the content of one's own thoughts that repeats or echoes in
his head (not loud), and the contents of other people's thoughts, although the
content is the same, but the quality is different
- "thought insertion or withdrawal": the contents of thoughts that are foreign
from the outside enter into his mind (insertion) or the contents of his mind are
taken out by something outside himself (withdrawal).
- “thought broadcasting”: the contents of his mind are broadcast out so that
other people or the public know about it.
(b)- "delusion of control" : delusions about himself being controlled by a
certain external force
- “delusion of influence”: delusions about himself being influenced by a certain
external force
- "delusion of passivity" : delusions about himself being helpless and resigned
to an outside force, (about "himself": clearly referring to body movements /
limbs or to special thoughts, actions, or sensations)
- "delusional perception" : an unnatural sensory experience, which has a very
strong meaning for him, usually mystical or miraculous.

(c) Auditory hallucinations:

- Hallucinatory voices commenting continuously on the patient's behavior
- Discuss about the patient among themselves (among the various voices
speaking)
- Another type of hallucinatory voice that comes from one part of the body.

(d) Other types of persistent delusions, which according to local culture are
considered unnatural and something impossible, for example regarding certain
religious or political beliefs, or powers and abilities above ordinary humans (eg
being able to control the weather, or communicate with alien beings from
Another World).

- Or at least two of the following symptoms must always be clearly present:

27
 (e) Persistent hallucinations of any of the senses, when accompanied by either
floating or semi-formed delusions with no apparent affective content, or
accompanied by persistent over-valued ideas, or when they occur every days
for weeks or months continuously.
(f) Thoughts that are broken or interpolated, resulting in incoherence or
irrelevant speech, or neologisms.
(g) Catatonic behavior, such as excitability, posture, or bowel flexibility,
negativism, mutism, and stupor.
(h) “negative” symptoms, such as infrequent speech apathy, and blunted or
inappropriate emotional responses, usually resulting in social withdrawal and
decreased social performance; but it should be clear that none of this is due to
depression or neuroleptic medication.

- The presence of the above typical symptoms has lasted for a period of one
month or more (does not apply to any nonspecific prodromal phase).
- There must be a consistent and meaningful change in the overall quality of
several aspects of personal behavior, manifested as loss of interest, no purpose,
no action, self-absorbed attitude, and social withdrawal.

Therapy
- Pharmacotherapy
- Psychotherapy
- Social therapy
- Occupational therapy
- Etc

Follow up
- Therapy evaluation
- Diagnostic evaluation
- Etc
(Maslim, R. 2019)

28
10. Differential diagnose?
NO DD Symptom
1. Hebephrenic Disturbed thinking and feeling flat out go together,
Schizophrenia mentally like children.
2. Paranoid Having irrational thoughts that cannot be denied,
schizophrenia hallucinations like being chased, responding
sensitively to everything as if others will do
something bad.
3. Catatonic Barely moving, restless or aimless movements,
Schizophrenia unwilling to communicate, the patient has no
interest in the surroundings.
(Kaplan, HI, Sadock, BJ 2017).

11. Additional examination?

1) CT Scan
Studies using computerized tomography (CT) have consistently shown
that the brains of schizophrenic patients experience enlargement of the third
and lateral ventricles and some degree of cortical volume reduction. Another
CT study reported abnormal cerebral asymmetry, reduced cerebellar volume,
and changes in brain density in schizophrenic patients
2) MRI
A number of reports have shown that the volume of the hippocampus-
amygdala complex and the parahippocampal gyrus is reduced in
schizophrenic patients. One recent study found decreases in brain areas in the
left hemisphere and not in the right hemisphere, although another study found
bilateral volume reductions. Several studies have linked reduced limbic
system volume to the degree of psychopathology or a measure of disease
severity.
3) PET (Positron Emission Tomography)
One PET study found that a sample of schizophrenic patients had
decreased metabolic activity in the left anterior portion of the thalamus as
measured by PET.
(Sadock, B.J., Sadock, V.A. 2022).

29
12. Working diagnose?
Axis 1: schizophrenia hebephrenic
Axis 2: paranoid personality traits
Axis 3: No diagnosis
Axis 4: didn’t pass army enterance exam
Axis 5: GAF currently 60-51, because Mr. M still recognizes his brother and
still knows where he is, which means he doesn't have people orientation and
place orientation disorders

13. Treatment?
Pharmacotherapy

Stage 1
Single AGK administration

First episode or never received AGK therapy before

Partial or no response

Stage 2
Provision of alternative single AGK (other than those given in stage 1)

Partial or no response

Stage 2A Stage 3
Administration of single AGP or AGK Clozapine

Partial or no response

Stage 4
Clozapine + (AGP, AGK and ECT)

No response

Stage 5
Administration of single AGP or AGK

30
 Stage 6
Combination therapy, i.e. AGK + AGP, combination AGK + ECT or AGK +
another agent (eg mood stabilizer)

Note :
- AGK : Second Generation Antipsychotics
- AGP : First Generation Antipsychotics
- ECT : Electroconvulsive Therapy

Non pharmacotherapy
1) Social skill training, This therapy will help the patient to be able to
communicate again. Patients will be given video tapes containing other
people and patients, drama plays in therapy, and homework assignments for
specific skills that are practiced.
2) Family interventions, this therapy will provide understanding to
the family about schizophrenia, what will happen to patient, ask them to
always support patient, and reduce family stress
3) Individual psychotherapy, this therapy will build a therapeutic
relationship so patient could feel safe (Kaplan & Sadock, 2022)

14. Complications?
Complications of schizophrenia if left untreated, can lead to extreme
physical, emotional, and behavioral problems that affect every area of the
person's life (Kaplan & Sadock, 2022)

15. Prognosis?
Quo ad vitam : dubia ad bonam
Quo ad functionam : dubia ad malam
Quo ad sanationam : dubia ad malam

16. SKDU?
3A Not an emergency
Doctoral graduates are able to make clinical diagnoses and provide
preliminary therapy in non-emergency situations. Doctor graduates are able to

31
 determine the most appropriate referral for the next patient treatment. Doctor
graduates are also able to follow up after returning from a referral.

17. NNI?
- QS. Al-Anbiya : 07
"And We did not send (messengers) before you (Muhammad), but some men
whom We gave revelation to them, so ask those who have knowledge, if you
do not know."
Interpretation : Better Mr. M pays tithe and prays to Allah swt, to get peace
of mind so if there are strange things, ask the doctor, not smart people and
believe in things that don't really exist, because knowledgeable people know
the best solution for Mr. M.

- Ar rum 21
“And among the signs of His power is that He created wives of your own
kind, so that you may tend to and feel at ease with them, and He created
between you love and compassion. Verily in that are signs for a people who
think”
Interpretation : it means live with a sense of love and peace

2.7. Conclusion
Mr. M 20 y.o has symptoms delusion paranoid, delusion bizare, delusion chase,
hallucination, thingking disorganized, so he experience schizophrenia hebephrenic
with paranoid personality

32
2.8. Conceptual Framework

Stressor

Precipitasy Factor (2 Predisposition

years ago didn’t pass Factor (Premorbid
enterance army exam) Factor)

Imbalance of
neurotransmitters

Increase Decrease
Dopamine Dopamine

Positive Negative
Symptoms Symptoms

Delusion Thought Hallucination thinking

with disorder
drawal

33
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