VSMMC DEPARTMENT OF PSYCHIATRY

THE CASE OF G.J:

“BUNSO”

SUBBMITTED TO: DR. CHEUNG

SUBMITTED BY: JOSHUA PIERRE A. VARELA

Informant 1: Wife Informant 2: Niece

Reliability: 60% Reliability: 40%

A case of GJ, 50 years old, male, married, Filipino, a Roman Catholic, born February 13, 1968,
unemployed, Mechanical Engineering graduate, residing at Purok 10, Brgy. Malingaw, Tubod,
Lanao Del Norte, seeking consult for the first time in this institution.

Chief Complaint
“Aggressive sa balay, daghan iyawyaw ug pula kaayo ang lawas” as verbalized by the patient’s
niece.

History of Present Illness

17 years prior to consult, in an unrecalled month of 2001, patient was in early training to
become a policeman in Ipil, Zamboanga when he started to have aggressive behavior. Patient’s
niece states: ”Igsuon gyud niya maka trigger, magyawyaw siya about sa iyang igsuon di daw siya
pinangga, wala siya tabangi nya mag jump from one idea to another in the same sentence.”
Patient was reported to be telling threats to people who approach him saying”kusgan ko,
patiyon tika, ayaw duol nako, pusilon tika.” Patient at the time claims that anyone who
approached him were people sent by his brothers and sisters who in his impression were out to
hurt him as explained by the wife. Patient is revealed to have become distant from the family
after deciding to become a policeman. Patient was noted to be especially angry about a certain
relative, described as the 5th or 6th degree cousin of the patient’s niece, Eugene, family name
unrecalled, who has become the family driver and a caretaker for one of the family’s houses.
Due to this, the patient was noted to be feeling left out by his siblings as claimed by both the
wife and the niece. On the same day of the incident, patient was allowed to calm down and fall
asleep, with the aggression not being evident the next day. Patient’s wife claims the patient can
remember some of what he said and apologizes about them. Patient was no longer allowed by
his wife to return to police training due to the incident. No similar episodes occurred in the
following years as claimed by the wife and claims function as a father and member of the
household is normal.
13 years prior to consult, in an unrecalled month of 2005, patient was reportedly displaying the
same aggressive behaviour similar to his previous episode due to the news of the death of his
sister, the 5th among the siblings and was the acting guardian of the accompanying niece, who
subsequently was the daughter of the 4th sibling also deceased. At this time, patient was noted
to repeatedly say phrases such as “ayahay si Eugene” and “ang tanang tarong nangamatay na”
the latter being referred to as his favorite line to say. This was when the patient’s wife
reportedly started giving “ALMAG” Aluminum-Magnesium hydroxide 500mg three times a day
whenever he had an episode as stated by the wife who added they had no medical or
psychiatric consult done to prompt such medication and was solely her decision. Patient was
allowed to calm down and fall asleep, with the aggression not being evident the next day. No
similar episodes occurred in the following years as claimed by the wife and claims function as a
father and member of the household is normal.

10 years prior to consult, in May 2008, patient’s mother died due to unrecalled cause, patient
was reportedly displaying the same aggressive behaviour similar to his previous episode
described as “saputon” towards people around him and to again to “Eugene” with a cease of
aggression once the patient was tired and sleepy. Patient was allegedly given “ALMAG” as
stated by the wife. The aggressive behaviour was allegedly non-evident the following morning.
No similar episodes occurred in the following years as claimed by the wife and claims function
as a father and member of the household is again normal.

3 years prior to consult, April of 2015, patient was described as “violente kaayo, dili manapat
manghadlok lang, gihilantan siya, nisulod sa pikas balay, nakigtabi” explained by the wife.
Patient was allegedly in the neighbor’s unlocked house without the owner’s permission,
speaking with the owner who had no problems entertaining the patient at the time as a guest
as explained by the wife. Patient was then brought to Misamis University Medical Center at
5:00 AM and then immediately referred to Tangub City Rehabilitation Center where the
patient’s wife states “gi-injeckan siya, unya naulian pag hapon.” Patient was admitted in the
said institution on that day and then discharged one month after due to a certain policy of
which the patient explains “kelangan daw one month after pa makagawas kung maadmit mao
daw ila policy.” Patient’s wife claims the patient was not diagnosed for the entire duration of
his admission. No similar episodes occurred in the months that followed as claimed by the wife
and claims function as a father and member of the household is again normal.

2 years prior to consult, May of 2016, the patient along with his wife and 2 children attended
their family reunion in Tangub, Lanao Del Norte. After reportedly having seen his siblings,
patient suddenly told his wife “pasaylo-a ko” repeatedly and was described to be in a fearful
mood and not wanting to be left alone verbalizing “inyo man ko patyon.” Patient remained in
this state for 2 hours only as claimed by the wife, after which patient again regains coherence
as claimed by the wife and apologizes for the things he had verbalized. Patient was allegedly
given “ALMAG” as stated by the wife. No similar episodes occurred in the year and months that
followed as claimed by the wife and claims function as a father and member of the household is
again normal.

2 days prior to consult, the patient with his wife and children were on vacation staying in a
beach resort in Siquijor. In the evening, patient was noted to intake several glasses of
Emperador as reported by the wife. An hour later, patient was mumbling non-understandable
words and was giving unusually long glares at his family members as described by the wife.
Patient’s behaviour had ceased in the hour that followed and was able to fall asleep for the
night. On their trip back to Lanao Del Norte the following morning on which Dumaguete was a
stop-over, patient requested to visit his niece in Talisay located in Camella homes, Lawaan.
Patient arrived there together with his wife and children on Wednesday afternoon, 1 day prior
to consult. Upon meeting his niece, patient’s wife explains “Taud-taud nagyawyaw na, suko na
sa ako ug sa akong anak.” Patient’s wife describes the patient as becoming red all over and
appearing very angry and noted to have pressured speech expressing violent threats to the
people around him similar to his previous episodes. Patient’s wife states having brought a blood
pressure apparatus for the trip and the patient’s blood pressure was taken with a result of
180/100. Persistence of symptoms prompted consult in this institution for the first time.
Past Medical and Psychiatric History

No allergies to food or drugs. No hypertension in the previous years as claimed by the wife. No
diabetes mellitus. No previous hospital admissions. Previous surgery was a removal of what was
described as a “cyst” containing powdery material from the plantar surface of the right foot in
an unrecalled year as explained by the patient’s wife. No previous psychiatric diagnosis as
claimed by the wife.

Family History
Heredofamilial hypertension noted among the patient’s siblings. No diabetes mellitus noted.
Patient is the youngest of 10 siblings, with the 6th and 7th being male and the rest female. The
fourth eldest sibling died of Breast Cancer and the fifth eldest died of Lung Cancer. Patient is
claimed to have bad relations with his siblings especially the eldest sister. Patient’s wife claims
only the 2 sisters who died of cáncer are supportive of him and his life decisions. Patient’s
eldest sister was reported to say “tan-awn nato kung maka survive na siya na wala ta” and that
his family was against his decision to become a policeman.

Personal History
Patient was delivered full term via NSVD, breastfed, raised in Tangub, Lanao Del
Norte. Patient studied elementary at Tangub Central Elementary School and studied
highschool at Tangub National Highschool. Patient graduated BS -Mechanical
Engineering in 1991 from CIT in Cebu City. Year unrecalled, patient worked as a
Mechanical Engineer in Saudi Arabia until end of contract as described by the
patient’s wife. Patient then decided to apply as a policeman in the year 2001.
Developmental milestones were achieved appropriately as claimed by the wife. No
hearing disabilities noted, no hearing or speech problems. No sleep difficulties
reported. Patient enjoys watching TV at home . Patient reportedly has no hobbies.
Patient’s wife claims that the patient is taking care of a few pigs and chickens
outside of their home to sell in the future. Patient is reported to have some friends
who he occasionally opens up to about daily life pro blems but is described as more
of an introvert who prefers to stay at home as described by his wife and his niece.
Patient is a non-smoker, occasional drinker of alcoholic beverages. No illicit drug
use. No jail time noted. No financial constraints as clai med by the patient’s wife.

Patient had one romantic relationship as claimed by the patient’s wife before
dating his current partner, a nurse who was also raised in Lanao Del Norte. They
had dated for 4 years starting in 1995 and has now been married for 19 years,
having two children, one female 17 years old, grade 12 and one male, 13 years old
grade 8.

Mental Status Examination

Patient is awake, non-cooperative, not oriented to time place and person, appearing poorly
groomed wearing dirty green shirt, plaid brown shorts and slippers with uncombed hair. Patient
has a low voice and does not maintain eye contact when being called. Patient’s affect is
inappropriate and patient’s mood is angry with non-understandable pressured speech spoken
at a fast rate, having aggressive behavior noted to be pacing back and forth with a clenched fist
verbalizing threatening ideations and having a stooped posture. MSE unable to be fully
performed due to patient being agitated and then sedated with Clozapine 100mg/tab 1 tab.

Clinical Formulation
Primary Impression: Schizophrenia
The characteristic symptoms of schizophrenia involve a range of cognitive, behavioural, and
emotional dysfunctions, but no single symptom is pathognomonic of the disorder. The
diagnosis involves the recognition of a constellation of signs and symptoms associated with
impaired occupational or social functioning. Individuals with the disorder will vary substantially
on most features, as schizophrenia is a heterogeneous clinical syndrome. This disease is
diagnosed by the patient’s psychiatric history and mental status examination. The lifetime
prevalence of schizophrenia appears to be approximately 0.3-0.7% and typically emerges
between the late teens and the mid-30s; peak age at onset of the first psychotic episode is in
the early- to mid-20s for males and in the late-20s for females.

Schizophrenia is taken into consideration because the patient fulfills the criteria as stated in
DSM-V for schizophrenia:
Criteria A: Patient presented with disorganized speech, disorganized behaviour, persecutory
delusions and negative symptoms for a significant period of time according to the patient’s
wife.

Criteria B: Patient presented the following symptoms which have persisted and have been
present to a significant degree:

 Patient is no longer employed and failed to return to police training.

 Patient was noted to have aggressive behaviour.
 Interpersonal relations between family members has become strained due to the
patients’ behavior.

Criteria C: The patient experienced continuous signs of disturbances that persist for at least 6
months. This 6-month period included at least 1 month of symptoms that meet Criterion A.

Criteria D: Schizoaffective disorder and depressive or bipolar disorder with psychotic features
have been ruled out because either 1) no major depressive or manic episodes have occurred
concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during
active-phase symptoms, they have been present for a minority of the total duration of the

active and residual periods of the illness. 


Criteria E: The disturbance is not attributable to the physiological effects of a substance (e.g., a

drug of abuse, a medication) or another medical condition. 
 


Differential Diagnosis
1. Schizophreniform disorder: This diagnosis was considered as the patient fulfilled the
DSM-V diagnostic criteria, however, this was ruled out due to the episodes of the
disorder exceeds 6 months duration.
2. Bipolar I Disorder: This diagnosis was considered as there are behavioural patterns
observed in the patient, such as irritability, diminished interest in almost all activities.
However, the patient does not fulfill the criteria to constitute a manic or depressive
episode.
 3. Disruptive Mood Dysregulation Disorder: This diagnosis was considered due to the
irritable mood of the patient and his aggressive behaviour towards family members and
neighbours. However, this was ruled out as the patient does not meet the criterion of a
chronic, severe persistent irritability or frequent temper outbursts which is a core
feature of the disorder.

Treatment and Management

Treatment for Acute Psychosis
Antipsychotics and benzodiazepines can result in relatively rapid calming of patients. With
highly agitated patients, intramuscular administration of anti-psychotics produces a more rapid
effect. An advantage of an antipsychotic is that a single in intramuscular injection of haloperidol
(Haldol), uphenazine (Prolixin, Permitil), olanzapine (Zyprexa), or ziprasidone (Geodon) will
often result in calming effect without excessive sedation.

Benzodiazepines are also effective for agitation during acute psychosis. Lorazepam (Ativan) has
the advantage of reliable absorption when it is administered either orally or intramuscularly.
The use ofbenzodiazepines may also reduce the amount of antipsychotic that is needed to
control psychotic patients.

Treatment during Stabilisation and Maintenance

In the stable or maintenance phase, the illness is in a relative stage of remission. The goals
during this phase are to prevent psychotic relapse and to assist patients in improving their level
of functioning. The patient would benefit from family therapy in addition to pharmacotherapy,
to educate family members on the treatment required for the patient, how to cope with a
family member with a psychotic disorder and family support to help family members deal with
stress.

Current Patient Medications:

 Clozapine 100mg/tab 1 tab OD HS

Prognosis
Several studies have shown that over the 5- to 10-year period after the first psychiatric
hospitalization for schizophrenia, only about 10 to 20 percent of patients can be described as
having a good outcome. More than 50 percent of patients can be described as having a poor
outcome, with repeated hospitalizations, exacerbations of symptoms, episodes of major mood
disorders, and suicide attempts. Despite these glum figures, schizophrenia does not always run
a deteriorating course, and several factors have been associated with a good prognosis.

The patient’s history shows that he has several good prognostic factors such as good premorbid
social and work history, mood disorder symptoms, being married and having good support
systems. He also has some poor prognostic factors such as an insidious onset, negative
symptoms and many relapses. Overall, the patient will hopefully remain in remission with
continued support from psychiatrists and family members, along with good compliance with his
medications and thus be able to function well within society and at home.