TUTORIAL REPORT BLOCK XIV

SCENARIO B

GROUP 8
Lecture Mentor: dr. Budi Utama. M.Biomed

Group Member:
Permata Puspasyari 702017010
Citra Trisdayuni 702019008
Natasya Jelita Putri 702019015
Amaliyah Khairani 702019017
Sischa Radila Susilawati 702019024
Muhammad Adli Zidan Oktavian 702019039
Odyse Raditya Hamonangan Naibaho 702019056
Maudita Nursanti 702019070
Elsy Hafidza 702019080
Reza 702019092

MEDICAL FACULTY
MUHAMMADIYAH UNIVERSITY OF PALEMBANG
2021
 FOREWORD

Thank to Allah SWT. for all his graces and gifts so that we can complete the
tutorial report entitled "TUTORIAL REPORT BLOCK XIV SCENARIO B" as a task
of group competence. Greetings always poured out to our honor, the great prophet
Muhammad (peace be upon him) and his family, friends, and followers until the end
of time.
We realize that this tutorial report is far from perfect. Therefore, we expect
constructive criticism and suggestions for future improvement.
In the completion of this tutorial report, we get a lot of help, guidance and
advice. On this occasion, we would like to express our respect and gratitude to:
1. Allah SWT has given his health and mercy.
2. Both parents who always provide material and spiritual support.
3. dr. Budi Utama. M.Biomed as a group 8 tutor.
4. Comrades-in-arms.
5. All parties involved in the creation of this tutorial report.
May Allah SWT reward all the deeds given to all those who compile and help
make this report and may this tutorial report be useful for us and the development of
science. May we always be in the care of Allah SWT.Aamiin.

Palembang, 27 September 2021

Writer

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 TABLE OF CONTENTS

Foreword ................................................................................................ ii
Table of Contents ................................................................................... iii
Chapter I Introduction
1.1 Background ................................................................................. 1
1.2 Purpose and Purpose ................................................................... 2
Chapter II Discussion
2.1 Tutorial Data ............................................................................... 4
2.2 Case Scenario .............................................................................. 4
2.3 Classification of Terms................................................................ 5
2.4 Identification of Problems ........................................................... 6
2.5 Priority of Problem ...................................................................... 7
2.6 Problem Analysis ........................................................................ 7
2.7 Conclusion .................................................................................. 30
2.8 Concept Framework .................................................................... 30
References ............................................................................................. 31

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 CHAPTER I
INTRODUCTION

1.1 Background
The Mental Health and Sublime Function Block is the XIV 5th Block of
the Curriculum Based on Doctor's Education Competency, Faculty of
Medicine, University of Muhammadiyah Palembang. This block learning is
very important to be studied in the block education component at the Faculty
of Medicine, University of Muhammadiyah Palembang.
On this occasion, a tutorial with the title "Bad Odor!" case study scenario
A that describes the case of Mrs. Luis, 19 years old, unmarried, student, was
taken to the Polyclinic of Prof Ernaldi Bahar Hospital with complaints of
frequent smelling bad smells. According to her mother, about 6 months ago,
after Mrs. Luis underwent a new student orientation period (ospek), she
began to show a change in behavior. Ms Luis seems to be daydreaming a lot
and is becoming more reserved. Ms Luis also said she did not want to
continue her studies. In the evening, Ms. Luis is often seen not sleeping and is
seen pacing in his room.
About 3 months ago, Ms Luis often asked her mother if she smelled bad
smell in the house. Ms Luis often looks restless and goes in and out of the
house with the excuse of wanting to get rid of the bad smell. Ms. Luis
repeatedly said that he wanted to drop out of college because his seniors
didn't like him. Ms. Luis also wants to move out of his neighborhood because
he believes his neighbors think he is a bad influence in his neighborhood. Ms.
Luis also told his mother that the police would be coming soon to arrest him.
Prior to this complaint, Ms Luis was known as a religious person, a
perfectionist and did everything in an orderly and careful manner. Ms Luis
doesn't have many friends. Luis' mother is the second of 3 children. His older
brother is a religious teacher and his younger brother studies at a boarding
school. His father was a religious leader and his mother was a housewife.

1
 Autoanamnesis:
At the time of the interview, Ms Luis still recognized her mother and knew
she was in the hospital. Ms Luis looked scared when she answered looking
shaky. Mrs. Luis admitted that she had smelled a bad smell since the second
day of new student orientation (ospek). On that day, Ms Luis arrived late and
was punished by her seniors. Ms. Luis just found out that the punishment
given was posting pornographic material on her social media.
Physical examination:
Compos mentis; Blood pressure 110/80 mmHg; Pulse 84 x/minute; RR 24
x/minute; temperature 36.8º C. Weight 60 Kg, Height 170 cm.
Psychiatry Status:
Appearance : Tall, good self-care, cooperative, look afraid, often looks at the
door when answering questions, minimal physical-eye-verbal
contact.
Speaking :Verbalization is clear and fluent but seems shaky.
Intelligence :Good memory, no amnesia, good orientation, impaired
discriminatory judgment, disturbed discriminative insight,
appropriate levelintelligence, no intellectual decline.
Emotion : Mood: Disforik
Afek : appropriate
Thought : Unrealistic, suspicious delusions.
Perception : Olfactory hallucinations (smelling foul odor)
Reality Testing Ability (RTA) : disturbed.
Insight : first grade

1.2 Purpose and Objective

As for the purpose and objectiveof the scenario tutorial report this time:
1. As a tutorial group assignment report that is part of the KBK learning
system at the Faculty of Medicine, University of Muhammadiyah
Palembang.
2. Can solve the case given to the scenario with analytical methods and
group discussion learning.

2
3. The objectives of the tutorial learning method.
4. Students can understand and understand new material that has been
taught in the learning process.

3
 CHAPTER II
DISCUSSION

2.1 Data Tutorial

Tutor : dr. Budi Utama. M.Biomed
Moderator : Permata Puspasyari
Board Secretary : Amaliyah Khairani
Desk Secretary : Citra Trisdayuni
Tutorial Time : Monday, 27 September 2021
13.00 - 15.30
Wednesday, 29 September 2021
13:00 - done
Regulation:
1. Mutual respect between tutorial participants
2. Use good and proper communication
3. On time

2.2 Case Scenario

"Bad odor!"

Mrs. Luis, 19 years old, unmarried, student, was taken to the Polyclinic of
Prof Ernaldi Bahar Hospital with complaints of frequent smelling bad smells.
According to her mother, about 6 months ago, after Mrs. Luis underwent a
new student orientation period (ospek), she began to show a change in
behavior. Ms Luis seems to be daydreaming a lot and is becoming more
reserved. Ms Luis also said she did not want to continue her studies. In the
evening, Ms. Luis is often seen not sleeping and is seen pacing in his room.
About 3 months ago, Ms Luis often asked her mother if she smelled bad
smell in the house. Ms Luis often looks restless and goes in and out of the
house with the excuse of wanting to get rid of the bad smell. Ms. Luis
repeatedly said that he wanted to drop out of college because his seniors
didn't like him. Ms. Luis also wants to move out of his neighborhood because

4
 he believes his neighbors think he is a bad influence in his neighborhood. Ms.
Luis also told his mother that the police would be coming soon to arrest him.
Prior to this complaint, Ms Luis was known as a religious person, a
perfectionist and did everything in an orderly and careful manner. Ms Luis
doesn't have many friends. Luis' mother is the second of 3 children. His older
brother is a religious teacher and his younger brother studies at a boarding
school. His father was a religious leader and his mother was a housewife.
Autoanamnesis:
At the time of the interview, Ms Luis still recognized her mother and knew
she was in the hospital. Ms Luis looked scared when she answered looking
shaky. Mrs. Luis admitted that she had smelled a bad smell since the second
day of new student orientation (ospek). On that day, Ms Luis arrived late and
was punished by her seniors. Ms. Luis just found out that the punishment
given was posting pornographic material on her social media.
Physical examination:
Compos mentis; Blood pressure 110/80 mmHg; Pulse 84 x/minute; RR 24
x/minute; temperature 36.8º C. Weight 60 Kg, Height 170 cm.

2.3 Classification of Terms

1. Daydream Pensive with thoughts everywhere (KBBI, 2015)
2. Perfectionist People who want everything to be perfect
(KBBI, 2015).
3. Quiet type People who don't talk much (KBBI, 2015).
4. Nervous A condition that describes the inability of the
body and mind to rest, relax, or concentrate
(KBBI, 2015).
5. Behavior Any or all of a person's total activities, especially
those that can be observed from the outside
(Dorland, 2015).
6. Pornography Messages in various forms of media that contain
obscenity or sexual exploitation that violates the
norms of decency in society (KBBI, 2015).

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2.4 Identification of Problem
1. Mrs. Luis, 19 years old, unmarried, student, was brought to the Polyclinic
of Prof Ernaldi Bahar Hospital with complaints of frequent smelling bad
breath.
2. According to her mother, about 6 months ago, after Mrs. Luis underwent a
new student orientation period (ospek), she began to show a change in
behavior. Ms Luis seems to be daydreaming a lot and is becoming more
reserved. Ms Luis also said she did not want to continue her studies. In the
evening, Ms. Luis is often seen not sleeping and is seen pacing in his
room.
3. About 3 months ago, Ms Luis often asked her mother if she smelled bad
smell in the house. Ms Luis often looks restless and goes in and out of the
house with the excuse of wanting to get rid of the bad smell. Ms. Luis
repeatedly said that he wanted to drop out of college because his seniors
didn't like him. Ms. Luis also wants to move out of his neighborhood
because he believes his neighbors think he is a bad influence in his
neighborhood. Ms. Luis also told his mother that the police would be
coming soon to arrest him.
4. Prior to this complaint, Ms Luis was known as a religious person, a
perfectionist and did everything in an orderly and careful manner. Ms Luis
doesn't have many friends.
5. Luis' mother is the second of 3 children. His older brother is a religious
teacher and his younger brother studies at a boarding school. His father
was a religious leader and his mother was a housewife.
6. Autoanamnesis
At the time of the interview, Ms Luis still recognized her mother and knew
she was in the hospital. Ms Luis looked scared when she answered looking
shaky. Mrs. Luis admitted that she had smelled a bad smell since the
second day of new student orientation (ospek). On that day, Ms Luis
arrived late and was punished by her seniors. Ms. Luis just found out that

6
 the punishment given was posting pornographic material on her social
media.
7. Physical examination:
Compos mentis; Blood pressure 110/80 mmHg; Pulse 84 x/minute; RR 24
x/minute; temperature 36.8º C. Weight 60 Kg, Height 170 cm.
8. Psychiatry Status:
Appearance : Tall, good self-care, cooperative, look afraid, often looks at
the door when answering questions, minimal physical-eye-
verbal contact.
Speaking :Verbalization is clear and fluent but seems shaky.
Intelligence :Good memory, no amnesia, good orientation, impaired
discriminatory judgment, disturbed discriminative insight,
appropriate levelintelligence, no intellectual decline.
Emotion : Mood: Disforik
Afek : appropriate
Thought : Unrealistic, suspicious delusions.
Perception : Olfactory hallucinations (smelling foul odor)
Reality Testing Ability (RTA) : disturbed.
Insight : first grade

2.5 Priority of Problem

Number 1: Mrs. Luis, 19 years old, unmarried, student, was brought to the
Polyclinic of Prof Ernaldi Bahar Hospital with complaints of frequent
smelling bad breath.
Reason : Because it was the main complaint that brought Ms Luis to the
RSJ, which if not managed properly, would interfere with activities and could
lead to complications.

2.6 Problem Analysis

1. Mrs. Luis, 19 years old, unmarried, student, was brought to the
Polyclinic of Prof Ernaldi Bahar Hospital with complaints of
frequent smelling bad breath.

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a. How are the anatomy and physiology related to the case?
Answer:
Lymbic system
The word “limbic” means “border”. Originally, the term
"limbic" was used to describe the peripheral structures surrounding
the basal region of the cerebrum, but as we have learned more about
the functions of the limbic system, the term limbic system has been
expanded to mean all of the neuronal pathways that regulate
emotional behavior and impulses. motivation (Guyton, 2014).
The main part of the limbic system is the hypothalamus, with
its associated structures. In addition to its role in regulating behavior,
this area regulates many internal conditions of the body, such as
body temperature, osmolality of body fluids, and the urge to eat and
drink and regulate body weight. These internal functions are
collectively called the vegetative functions of the brain, and their
regulation is closely related to behavior (Guyton, 2014).
Hypothalamus
The hypothalamus, a small structure within the diencephalon,
is an important component of neural circuits that regulate not only
emotion, but also autonomic, endocrine, and several somatic
functions. In addition to its connections with other components of
the limbic system, it is also associated with various visceral and
somatic nuclei of the brainstem and spinal cord and provides outputs
that regulate pituitary gland function. On its inferior surface, the
hypothalamus is bounded rostrally by the optic chiasm and caudally
at the posterior edge of the mammillary body. The area of the
hypothalamus between these two structures is called the tuber
cinereum, giving rise to the median crest, which is continuous with
the infundibular trunk and then the posterior lobe of the pituitary
(Kaplan and Sadock, 2010).
Central nervous system (CNS)

8
 In the central nervous system, the brain and spinal cord are
the main centers for the correlation and integration of neural
information. The spinal cord lies within the vertebral canal of the
vertebral column and is covered by three meninges; dura mater,
arachnoidea mater and pia mater. The brain is located in the cranial
cavity and is connected to the spinal cord through the foramen
magnum. Conventionally, the brain is divided into three main parts.
These parts are the rhombencephalon, mesencephalon, and
prosencephalon. The rhombencephalon is divided into the medulla
oblongata, pons, and cerebellum. In the medulla oblongata, there are
many collections of neurons called nuclei to transmit ascending and
descending nerve fibers (Snell, 2012).
Nervous system (neuromuscular junction)
At the neuromuscular junction, nerve cells and muscle cells
are not actually in contact with each other. The gap between these
two structures is too large to allow the transmission of an electrical
impulse between them. Thus, as at a nerve synapse, there is a
chemical messenger that transports signals between the nerve
endings and the muscle fiber. This neurotransmitter is referred to as
acetylcholine (ACh) (Sheerwood, 2016).
Neurotransmitter Between the ends of one nerve cell with
another nerve cell to form a gap called a synapse. The nerve endings
that transmit impulses are called presynaptic cells, while those that
receive impulses are called postsynaptic cells. The delivery of these
impulses involves chemical mediators called neurotransmitters. In
their role as impulse conductors, neurotransmitters can be inhibitory
(inhibitory neurotransmitters) and excitatory (excitatory
neurotransmitters) (Guyton, 2014).
The most common excitatory neurotransmitter in the CNS is
glutamate, while the most common inhibitory neurotransmitter is
GABA. The inhibitory neurotransmitter in the spinal cord is glycine.
Acetylcholine and norepinephrine are the most important

9
 neurotransmitters in the autonomic nervous system. Other important
neurotransmitters are dopamine, serotonin, and various types of
neuropeptides (Guyton, 2014).

b. What does it mean for Ms. Luis to be brought to the Polyclinic of

Prof Ernaldi Bahar Hospital with complaints that she often smells
bad?
Answer:
It means Ms. Luis experiences olfactory hallucinations
which are positive symptoms of Schizophrenia. These hallucinations
involve various odors that are not present. This odor is usually
unpleasant, such as the smell of vomit, urine, stool, smoke, or rotting
flesh.

c. What are the possible causes of Ms Luis complaining of smelling

bad odors?
Answer:
Smell that feels strange like smelling smoke and smells bad can be
called dysosmia. There are many possible triggers for this condition,
for example:
 Inflammation around the nose (rhinitis) or sinuses (sinusitis),
such as due to allergies, infections (including the Corona virus
infection that causes COVID-19), exposure to smoke or other
irritants, excessive scratching, entry of foreign objects
 Benign or malignant tumors around the nose or sinuses, such as
polyps, fibromas, nasopharyngeal carcinoma
 Nerve disorders around the nose and head, such as diabetes,
stroke, multiple sclerosis
 Other factors, such as reflux of stomach acid into the throat,
hormonal fluctuations, drug side effects, psychological
disorders, and so on

10
  Olfactory hallucinations. Sufferers of olfactory hallucinations
will smell good or unpleasant odors, even though the smell is
not actually there. This can be caused by Schizophrenia,
Psychosis, Bipolar disorder, Depression with psychotic
disorders, Delirium or dementia Borderline personality disorder,
Post-traumatic stress disorder, Alzheimer's disease, Brain
tumors, Head injuries, Alcohol and drug abuse
(Waters and Fernyhough, 2017)

d. What is the relationship between age and sex in the case?

Answer:
The incidence of schizophrenia is higher in men than women.
The incidence in the community is around 1-2% of the population
with schizophrenia, in men usually between 15-25 years and women
between 25-35 years (Elvira, 2013).

e. What is the complaint mechanism in the case?

Answer:
Social factors, biological factors, and internal problems → stimulates
the hypothalamus to release hormones in the adrenal medulla →
There is an increase in the biosynthesis of dopamine, norepinephrine,
and epinephrine → increased dopamine in the mesolimbic pathway
→ positive symptoms of schizophrenia appear → hallucinations
(smelling a foul smell) (Price, 2015).

2. According to her mother, about 6 months ago, after Mrs. Luis

underwent a new student orientation period (ospek), she began to
show a change in behavior. Ms Luis seems to be daydreaming a lot
and is becoming more reserved. Ms Luis also said she did not want to
continue her studies. In the evening, Ms. Luis is often seen not
sleeping and is seen pacing in his room.

11
a. What does it mean according to his mother, about 6 months ago,
after Bu Luis underwent a new student orientation period (ospek), he
began to show a change in behavior. Ms Luis seems to be
daydreaming a lot and is becoming more reserved. Ms Luis also said
she did not want to continue her studies.?
Answer:
The meaning is that accepting new student orientation
(ospek) is a psychosocial stressor factor, People who have
psychosocial stressors are at greater risk of developing schizophrenia
than people who do not have psychosocial stressors, so Ms. Luis It
was seen that there was a change in his behavior which indicated he
was in the active phase of schizophrenia (Maslim, 2013).

b. What is the relationship between Ms Luis undergoing ospek with

behavior change?
Answer:
According to ICD-10 behavioral change and social
withdrawal are one of the negative symptoms of schizoprenia which
strengthen the possibility that ms Luis is suffering from schizo.

c. What is the mechanism of behavior change, daydreaming a lot and

being more quiet?
Answer:
Stressors → stimulate the occurrence of schizophrenia → abnormal
transmission of neurotransmitters (especially dopamine) in various
parts of the brain → decreased levels of dopamine in the
mesocortical area → dopaminergic neurons present to the cerebral
cortex (eg frontal lobes), which function to regulate thoughts,
decision making, language, and feelings → dopamine transmission
disorders are considered to cause negative symptoms in people with
schizophrenia → behavioral changes, often daydreaming, more
reserved (Price and Wilson, 2015).

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 d. What does it mean at night, Ms. Luis is often seen not sleeping and
is seen pacing in his room.
Answer:
It means no sleep (insomnia) is to indicates increased
alertness, pacing in the room shows agitation (restlessness) due to
increased dopamine and norepinephrine.

e. What is the impact of changing behavior, daydreaming a lot and

being more quiet?
Answer:
Ms. Lois shows negative symptoms of schizophrenia,
praschizophrenia where the impact can be in the form of impaired
social function and patient education.

3. About 3 months ago, Ms Luis often asked her mother if she smelled
bad smell in the house. Ms Luis often looks restless and goes in and
out of the house with the excuse of wanting to get rid of the bad
smell. Ms. Luis repeatedly said that he wanted to drop out of college
because his seniors didn't like him. Ms. Luis also wants to move out
of his neighborhood because he believes his neighbors think he is a
bad influence in his neighborhood. Ms. Luis also told his mother that
the police would be coming soon to arrest him.
a. What does it mean Ms Luis often asks her mother if she smells bad
in the house. Ms Luis often looks restless and goes in and out of the
house with the excuse of wanting to get rid of the bad smell?
Answer:
The occurrence of olfactory hallucinations, is a false
perception of smell that often occurs in general medical disorders.

b. What are the types of personality disorders and their interpretation of

the case?
Answer:

13
Cluster 1
is a group of strange or eccentric individuals. Consists of 3 groups,
namely
1. Paranoid: Distrust or suspicion that permeates others, feels that
others are envious of them.
2. Schizoid: A pervasive pattern of opening up from social
relationships and very limited emotional expression in
interpersonal relationships.
3. Schizotypal: A pattern of social and interpersonal deficits
characterized by feelings of discomfort as an increase in close
relationships and characterized by cognitive distortions or
perceptions and eccentric behavior
(PPDGJ III, 2013).
Cluster 2
Is a dramatic, emotional, or eratic group of individuals. Consists of -
Histirionic : Pervasive pattern of emotion seeking attention.
1. Narcissistic: A pervasive pattern of grandiosity (feeling great) in
fantasy and behavior, wanting to be admired by people and
lacking empathy.
2. Antisocial: Pervasive pattern of indifference and violation of the
rights of others
3. Boundary: Pervasive pattern of instability in interpersonal
relationships, self-image, affect, and impulse control (stimuli)
(PPDGJ III, 2013).
Cluster 3
Anxious individuals or networks. This group consists of:
1. Avoidan : A pervasive pattern of social inhibition, feelings of
inadequacy, and hypersensitivity to negative evaluations.
2. Dependent: A pervasive and excessive need to be cared for by
others that results in submissive behavior and "sticky" fear of
separation.

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 3. Obsessive-compulsive (Anankastic): Pervasive pattern of
obsession (preoccupation) with regularity, perfectionism, and
mental and interpersonal control at the expense, adjustment, and
efficiency (PPDGJ III, 2013).

Interpretation: Obsessive-Compulsive (Anankastic) personality

disorder.

c. What is the pathophysiology of restlessness in this case?

Answer:
Predisposing factors: anankastic personality disorder → social
interaction problems → stressors → dopamine & serotonin
neurotransmitter imbalance → stimulates the hypothalamus (adrenal
medullary hormone release) → increased biosynthesis (dopamine,
epinephrine, and norepinephrine) → increased alertness →
restlessness (Price and Wilson, 2015).

d. What are the classifications of hallucinations?

Answer:
According to Yosep (2007:79), the types of hallucinations are
divided into 8, namely:
1. Auditory hallucinations (auditive, acoustic)
Most often encountered can be a ringing sound or noise that
does not contain meaning, but more often heard as a word or
sentence that meaning.
2. Visual hallucinations (visual, optical)
More common in delirium (organic disease). Usually often
appears together with a decrease in consciousness, causing fear
due to the images that occur.
3. Olfactory hallucinations (olfactory)

15
 These hallucinations are usually in the form of smelling
something that smells certain and feels bad, catapulting the
sufferer to feel guilty.
4. Taste hallucinations (gustatory)
Although rare, usually along with olfactory hallucinations,
sufferers feel like tasting something. Gastric hallucinations are
less common than gustatory hallucinations.
5. Touch hallucinations (tactile)
Feeling of being touched, touched, blown or like a caterpillar,
moving under the skin. Especially in the state of toxic delirium
and schizophrenia.
6. Sexual hallucinations of the
Patient feeling touched and raped, often in schizophrenia with
delusions of grandeur, especially regarding the organs.
7. Kinesthetic hallucination
Suffering feeling moving in a space or moving limbs, for
example "phantom phenomena" or amputated limbs are always
moving (phantom limb). Often in use in certain toxic conditions
due to certain drugs.
8. Visceral hallucinations The
emergence of certain feelings in the body.

e. What does Ms. Luis repeatedly said that he wanted to drop out of
college because his seniors didn't like him?
answer:
It means Ms. Luis suffers from paranoid delusions that lead
to these complaints.

f. Ms. Luis also wants to move out of his neighborhood because he

believes his neighbors think he is a bad influence in his
neighborhood?
Answer:

16
 That's why Ms. Luis had persecutory delusions and delusions
of pursuit because Ms. Luis was found to have thought content
disorders in the form of false beliefs as if people around him were
talking about him (persecutory delusions). And the belief that there
are people who want to do evil to themselves and their families
(delusions of pursuit) (Utami and Septa, 2017).

g. What does Ms. Luis Luis also told his mother that the police would
be coming soon to arrest him?
Answer:
It means that Ms. Luis is having a type of delusion,
persecutory delusion in particular. Individuals with persecutory
delusions erroneously believe that others are trying to cause them
physical, psychological or social harm. One reason for the
persistence of the threat beliefs is a failure to obtain and process
disconfirmatory evidence as a result of the use of safety-seeking
behaviour (Freeman, 2016).

h. What are the types of delusions?

Answer:
The types of delusions, namely:
1. Bizarre delusions: False, impossible and bizarre beliefs
(example: extraterrestrials implanting electrodes in the human
brain)
2. Systematic delusions: false beliefs or beliefs that are associated
with one theme/event (example: people being chased by the
police or mafia)
3. Nihilistic delusions: the mistaken feeling that the self and the
environment or the world do not exist or are headed for the end
of the world
4. Somatic delusions: mistaken beliefs involving bodily functions
(example: believing the brain is melting)

17
5. Paranoid delusions: including delusions of grandeur, delusions
of pursuit/persecutory, delusions of reference, and delusions of
control.
a. Delusions of grandeur: belief or belief, usually psychotic in
nature, that one is very powerful, very powerful or very big.
b. Persecutory delusions: a delusion that characterizes a
paranoid person, who thinks he or she is the victim of an
attempt to harm him, or that drives him to fail in his actions.
This belief is often manifested in the form of an imaginary
conspiracy, doctors and the patient's family are suspected of
conspiring together to harm, damage, injure, or destroy him.
c. Delusion of reference (delusion of reference): a false belief
that believes that the behavior of another person must be
slanderous, harmful, or will harm him.
d. Controlled delusions: the mistaken belief that one's desires,
thoughts, or feelings are controlled by outside forces.
Including:
1. Thoughts withdrawal: delusion that his mind is being
pulled by other people or other forces
2. Thought insertion: delusion that his mind has been
inserted by another person or another force
3. Thought broadcasting: the delusion that one's thoughts
are known to others, broadcasts in the air
4. Thought control: delusions that one's mind is controlled
by another person or some other power
6. Jealousy delusions: mistaken beliefs stemming from
pathological jealousy about an unfaithful partner
7. Erotomania: mistaken belief, usually in women, believing that
someone really loves them
(Elvira, 2014).

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i. What is the mechanism for delusions?
Answer:
Stresssor (punishment from seniors for posting pornographic
material) → Stimulates hypothalamus release of adrenal medulla
hormones → Occurs dopamine, norepinephrine, epinephrine
biosynthesis → Dopamine in the mesolimbic pathway → Positive
symptoms of schizophrenia appear → delusions.

j. What are the types of schizophrenia?

Answer:
Several types of schizophrenia were identified by the variable
clinics according to ICD-10 among others as follows:
a. Paranoid schizophrenia
The main characteristic is the presence of delusions of chasing
and auditory hallucinations but cognitive and affective functions
are still good.
b. Hebephrenic Schizophrenia
Feature primarily is the conversation that is chaotic, behavior
behavior of chaotic and flat affect or inappropiate.
c. Catatonic schizophrenia
Feature primarily is interference on psychomotor which may
include motoric immobility , the activity of motor overload,
negativesm the extreme and movements that are not controlled.
d. Schizophrenia is not detailed
Symptoms do not meet the criteria for paranoid, hebephrenic or
catatonic schizophrenia.
e. Post- schizophrenic depression.
f. Residual schizophrenia
g. At least never experience one episode schizophrenia and this
time the symptoms are not prominent.
h. Schizophrenia simplex.
i. Other Schizophrenia

19
 j. Unclassified schizophrenia
(Elvira, 2014)

k. How to assess the GAF scale in a case?

Answer:
GAF in this case : 60-51 : moderate, severe disability.

4. Prior to this complaint, Ms Luis was known as a religious person, a

perfectionist and did everything in an orderly and careful manner.
Ms Luis doesn't have many friends.
a. What does it mean Ms Luis is known as a religious person, a
perfectionist and does everything in an orderly and careful manner.
Ms. Luis doesn't have many friends?
Answer:
Because Ms. Luis suffers from obsessive-
compulsive/anankastic personality disorder, she complains of being
a perfectionist and doing things in an orderly and careful manner.

b. What does Ms Luis' chief complaint have to do with being religious,

being a perfectionist and doing things in an orderly and careful
manner?
Answer:
The relationship between Ms. Luis, who is known as a
religious person, a perfectionist and does everything in an orderly
manner with the emergence of complaints in the case, is that it
indicates that she has anankastic personality disorder or obsessive-
compulsive personality disorder, a personality disorder that has the
characteristics of a limited emotional, regularity, persistence,
stubbornness and indecision. This personality disorder has a basic
nature with a pattern that goes into perfectionism and inflexibility.
Where the course of this anankastic personality disorder can be
varied and unpredictable and the disorder can be a sign of

20
 schizophrenia so that it will cause complaints in cases (Harold
Kaplan et al, 2010).

5. Luis' mother is the second of 3 children. His older brother is a

religious teacher and his younger brother studies at a boarding
school. His father was a religious leader and his mother was a
housewife.
a. What does Ms Luis mean the second child of 3 siblings. His older
brother is a religious teacher and his younger brother studies at a
boarding school. His father was a religious leader and his mother
was a housewife.
Answer:
The meaning comes from a religious family, contrary to the
punishment he received. which can cause pressure on her, so that
when Ms. Luis got punished for posting pornography she felt that
she did not deserve to be supported by other predisposing factors
such as anankastic personality.

b. What is the relationship between family status and Ms Luis'

personality disorder?
Answer:
The relationship is the social status of Mr. T allows him to
experience a sense of urgency to be able to pass his thesis (father
with anankastic personality disorder), so that when he does not fulfill
this desire, social stressors will arise. So that Axis IV will be marked
by problems with the "primary support group" (family), educational
problems, and problems related to the social environment (Maramis,
2013; Maslim, 2013).

c. What is the relationship between family status and chief complaint?

Answer:

21
 There is no relationship between family status and the main
complaint experienced by Ms. Luis. But her religious family history
and college problems caused Ms. Luis. When the stress appears, it
can cause psychotic symptoms.

6. Autoanamnesis
At the time of the interview, Ms Luis still recognized her mother and knew
she was in the hospital. Ms Luis looked scared when she answered looking
shaky. Mrs. Luis admitted that she had smelled a bad smell since the
second day of new student orientation (ospek). On that day, Ms Luis
arrived late and was punished by her seniors. Ms. Luis just found out that
the punishment given was posting pornographic material on her social
media.
a. What meaning is there during the interview, Ms Luis still recognizes
her mother and knows that she is in the hospital. Ms Luis looked
scared when she answered looking shaky.
Answer:
It means that Ms. Luis doesn’t have disorientation of time,
place, and person because in this case 6a. Ms. Luis still recognizes
his mother and the place where she is. And it can be rule out the
differential diagnosis of organic mental disorders (GMO).

b. What is the pathophysiology of looking scared and shaking?

Answer:
Predisposing factors: anankastic personality disorder → social
interaction problems + stressors (punishment by her senior and
religious family (guilt)) → dopamine & serotonin neurotransmitter
imbalance → stimulates the hypothalamus (adrenal medulla
hormone release) → increased biosynthesis (dopamine, epinephrine,
and norepinephrine) → increased alertness → agitation (looks
frightened and shaking) (Price and Wilson, 2015).

22
 c. What does the chief complaint have to do with the history of being
punished by his senior?
Answer:
The relationship is that the punishment given by his senior is
a stressor from his illness, namely paranoid schizophrenia.

7. Physical examination:
Compos mentis; Blood pressure 110/80 mmHg; Pulse 84 x/minute; RR 24
x/minute; temperature 36.8º C. Weight 60 Kg, Height 170 cm.
a. How are the results of the physical examination interpreted?
Answer:
Physical Normal In this case Interpretation
examination
Conciousness Compos Compos mentis Normal
mentis
Blood 100/70-140/90 110/80 mmHg Normal
pressure mmHg
Pulse 60-100 84x/minute Normal
x/minute
Respiratory 16-24 x/minute 24x/minute Normal
rate
Temperature 36.5-37.5oC 36.8°C Normal
Body Mass 18,5-24,9 20,7 Normal
Index (BMI)

b. What do normal physical examination results mean?

Answer:
Meaning below Axis III the patient is normal, there are no problems
with general medical conditions, or there are no other health
problems.

23
8. Psychiatry Status:
Appearance : Tall, good self-care, cooperative, look afraid, often looks at
the door when answering questions, minimal physical-eye-
verbal contact.
Speaking :Verbalization is clear and fluent but seems shaky.
Intelligence :Good memory, no amnesia, good orientation, impaired
discriminatory judgment, disturbed discriminative insight,
appropriate levelintelligence, no intellectual decline.
Emotion : Mood: Disforik
Afek : appropriate
Thought : Unrealistic, suspicious delusions.
Perception : Olfactory hallucinations (smelling foul odor)
Reality Testing Ability (RTA) : disturbed.
Insight : first grade
a. How is the interpretation of the results of the psychiatric status
examination?
Answer:
Component In Case Interpretation
Appearance Tall Normal
Self-care Normal
Cooperative Normal
Look afraid Ab-normal
Often looks at the door Ab-normal
when answering
questions
minimal physical-eye- Ab-normal
verbal contact
Speaking Verbalization is clear and Ab-normal
fluent but seems shaky
Intelligence Good memory, Normal
Good orientation Normal
Impaired discriminatory Ab-normal
judgment
Disturbed discriminative Ab-normal
insight,
Appropriate level Ab-normal
intelligence.
No intellectual decline Normal
Emotion Mood : Disforik Ab-normal

24
 Afek : appropriate Ab-normal
Thought Unrealistic, suspicious Ab-normal
delusions.
Perception Olfactory hallucinations Ab-normal

Reality Testing Disturbed. Ab-normal

Ability (RTA)
Insight first grade Ab-normal

9. How to diagnose in cases?

Answer:
ask his psychiatrist status:
1. Facial romance: looks scared, tensed;
2. Perception: olfactory hallucinations and illusions are absent;
3. Thoughts: incoherent, thought content: paranoid/suspicious delusions
4. mood: anhedonia
5. affective: congenial
6. Behavior: tense;
7. Speech: tensed Ability to assess reality (RTA): moderately disturbed

10. What is the differential diagnose in the case?

Answer:
Paranoid SKIZO- Affect/Mood Disorder
Schizophrenia AFFECTIVE
delusion Schizophrenia + There are periods of
clear hallucination affective disorder depression/manic
Negative symptoms at the same time periods/a mixture of both
Disorganized affective disorder No psychotic disorders
behavior 
Talking messed up depressive/manic/
Minimum 1 month mixed disorder

11. What are the supporting examinations in the case?

Answer:
MMPI: untuk memudahkan para ahli di bidang kesehatan mental dalam
melakukan diagnosis berbagai gangguan mental.

25
12. What is the working diagnosis in cases??
Answer:
a) Aksis I: F20.0 Skizofrenia Paranoid
b) Aksis II: F60,5 Kepribadian anakastik
c) Aksis III: tidak ada diagnosis
d) Aksis IV: Masalah pendidikan dan lingkungan sosial
e) Aksis V: Skala GAF 60-51 (Moderate)

13. How to treat in cases?

Answer:
Antipsychotics:
a. Dopamine receptor antagonist (typical) = generation 1
b. Serotonin-dopamine antagonist (atypical) = generation 2

1. Dopamine Receptor Antagonists

Top choice for positive symptoms
Examples of drugs  haloperidol, chlorpromazine
Work mechanism:
Inhibits dopaminergic receptors in mesocortical, anterior mesolimbic,
nigrostiatal.
Side effects:
High extrapyramidal symptoms
1. Extrapyramidal symptoms (EPS): dystonia, parkinsonism, tardive
dyskinesia and akathisia
2. dystonia; Twisted neck, squinted eyes, stiff and rigid muscles
3. Parkinsonism; tremor, rigidity, motor slowing, drooling >>, face
mask
4. Tardive dyskinesia: Facial and tongue movements  chewing
continuously, sticking out tongue, grinning
5. akathisia; can't keep still, restless. The most common symptoms of
EPS

26
2. Serotonin-dopamine antagonists
Effect can overcome positive symptoms and negative symptoms
Examples of drugs  risperidone, clozapine
Work mechanism:
Strong antagonist to both serotonin (particularly 5-HT2A) and
dopamine D2 receptors.
The extrapyramidal side effects of the syndrome are LESS.
Risperidone dose 2-8 mg/day, 1-2x/day
tablet preparations: 1 mg, 2 mg, 3 mg
Half-life 20 hours
a. Generation I Antipsychotics / Typical Antipsychotics
b. Reduces dopamine hyperactivity by blocking D2 receptors
(receptor antagonists) throughout the brain
1. Mesolimbic D2 receptor blockade<< positive symptoms
2. Mesocortical D2 receptor blockade exacerbate negative and
cognitive symptoms
3. D2 receptor blockade in the nigostriatal parkinsonism
movement disorder (extrapyramidal symptoms/EPS) 
Chronic: hyperkinetic movements (tardive dyskinesia)
4. Tuberoindundibular D2 receptor blockadeincrease in
prolactin:galactorrhea, amenorrhea, bone demineralization,
sexual dysfunction, weight gain

Non pharmacology
1. Psychoeducation
a. Increase patient and family understanding of the disease,
symptoms, treatment and the role of the family
b. Life planning that is more realistic and able to be implemented
2. Family intervention
a. Involve family
b. Family education, improving communication in the family,
problem solving skills.
3. Rehabilitation

27
 a. Vocational therapy. social skills training, cognitive remediation.
b. Improving skills in socializing, establishing interpersonal
relationships, integrity to the community and acquiring work skills
(Elvira, 2014)

14. What are the complications in the case?

Answer:
Suicide, disrupted work and environment, drug abuse.

15. What is the prognosis in cases?

Answer:
Dubia ad malam

16. What is SKDU in the case?

Answer:
3A : Bukan Gawat Darurat

17. What Islamic Values are related to the case?

Answer:
Al-anbiya’ : 7

We do not send messengers messengers before thee (Muhammad), but

some of the men that we give revelation to them, then ask ye to the
people who have knowledge, if you are not aware.

At-taubah : 103

28
Take zakat from some of their wealth , with that zakat you clean and
purify them and pray for them. Verily, your prayer (becomes) peace of
soul for them. And Allah is All- Hearing, All- Knowing.

29
2.7 Conclusion
Ms Luis, 19 years old, olfactory hallucinations, daydreams a lot, is more
quiet, doesn't sleep and often paces in her roombecause of having
schizophrenia paranoid and personality disorder anankastic with stressor (the
punishment given by his senior)

2.8 Conceptual Framework

Internal factor: External factor:

- Genetic (problem of college)
- Neurotransmitter

Stressor Dissfunction Personality

psikososial neurotransmitter disorder
anankastic
r

Symptoms of psychosis
& mental disorders

Schizofrenia
paranoid

Daydream more Smelled foul Not sleeping &

silent oders seems to be
pacing in her
room

30
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