PSYCHIATRY

A case analysis in Course

Integration

ADINNU-BHETWAL-BRAVO-BUHAYO-MERCADO-MOODLEY-PEÑA-SAUÑA-TIU-TROMPETA-VILLANUEVA
 PEÑA

Case:
MJ is a 22 yr old male student who was brought to the hospital one night by
his dorm guardian. He has no psychiatric history but has been having difficulty
coping in class and often worried about his grades. He had recently received a
failing score for his first long exam that day. Last night during dinner, his
guardian noticed fresh blood on his shirt sleeves. The guardian noticed scars
on his left arm and fresh blood from a recent cut. His guardian was worried
and brought him to the hospital. You are assigned in the emergency room and
saw the patient.

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 PEÑA

Pertinent data:
- 22 years old/ Male
- No psychiatric history

Dinner time prior

Day-time of the to consult: Chief
- Difficulty
consult: - Fresh blood on Complaint:
coping in class
- Received a shirt sleeves Fresh Blood
- Often worried
failing mark on - Scars on Left from a recent
about his grades
first long exam Arm scar

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GUIDE QUESTIONS

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 PEÑA

1. What are your first thoughts?

● Accidental Wound

● Self-inflicted wound

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 PEÑA

Apply Treatment on the wound

● Depending on the severity of the wound

First Aid

Suturing if the cut is deep

Anti-tetanus

Antibiotics

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 PEÑA
Ask open ended questions followed by clarification while
inspecting the arm
● This will help identify the real cause of the wound/cut
● Maintain eye contact and be in a relaxed position
● Do active listening
● Build rapport

*Inspect the patient’s other body parts

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 PEÑA
·How or what are you feeling right now?

·What were you doing before you got this wound?

·How is your relationship with your parents at home?

·How about your friends and classmates at school?

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 SAUÑA

When the patient reports sad mood, or

loss of interest in pleasurable activities,
or when they appear to be depressed,
clinicians should elicit responses to
certain questions.

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 SAUÑA
*Ask the patient if he has had any suicidal thoughts and
depending on the answer we can proceed to additional
questions.
· What is or are the things that’s troubling you?

· Did you ever feel/think about harming yourself?

· Do you feel life’s worth living?

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 SAUÑA

We can try to interview the guardian of the patient for additional

information
History of suicidal behavior,
including ideations and
threats, previous attempts of
those events, family history of
suicide and suicide attempts

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 BUHAYO

2. What will be your response and behavior to the patient?

- First have a keen and thorough
observation of the patient the
moment I first see him

- Building rapport with the patient (if

the patient is conscious) wherein I
acknowledge the patient’s discomfort
and reassure him that I am willing to
offer my help

- Engaging in active listening and being

deliberate about the patient’s non-
verbal cues or body language
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 BUHAYO

Ideal physician behavior

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 BUHAYO

Confidence
- Refers to the state-of-the-art medical
practices wherein experience in treating
specific medical conditions or performing
procedures is exuded by the physician’s
manner of speaking

- Physician is not disturbed by the patient’s

queries about medical information acquired
from other sources

- Physician is at ease in the presence of the

patient, family members, and medical
colleagues
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 BUHAYO

Empathetic
- Physician makes eye contact with the
patient as well as the family members,
and correctly interprets patient’s
verbal and non-verbal cues

- Physician repeats patient’s concerns

and shares personal stories which are
relevant

- Physician speaks in sympathetic and

calm tone of voice

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 BUHAYO

Humane
- Physician uses appropriate
physical contact, and is
attentive; He or she shows
willingness to spend adequate
time with the patient through
unhurried movements

- Physician helps arrange

needed non-medical assistance
for the patient

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 BUHAYO

Personal
- Physician asks patient about
their lives, discusses own
personal interests, uses
appropriate humor, and
acknowledges the patient’s
family

- Physician remembers the

details about the patient’s life
from previous visits

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 BUHAYO

Forthright
- Physician doesn’t sugarcoat or
withhold information and does
not use medical jargon

- Physician is capable of
explaining the pros and cons of
the treatment

- Asks the patient to recap the

conversation in order to ensue
understanding
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 BUHAYO

Respectful
- Physician offers explanation or apology
if the patient is kept waiting

- Physician listens carefully and does not

interrupt when the patient is describing
the medical concern; He or she provides
choices to the patient as appropriate
but is also willing to recommend a
specific course of treatment

- Solicits patient’s input in treatment

options and scheduling

- Takes care to maintain patient’s

modesty during physical examination 19
 BUHAYO

Thorough
- Physician provides detailed
explanations, gives
instructions in writing,
follows a timely manner,
and expresses to the
patient the desire to consult
other clinicians or research
literature on a difficult case

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 ADINNU
3. What will you do?
A. Approach the patient
B. Probe
C. Reflective listening
D. Assess for patient’s disposition
E. Further history taking
F. Request for laboratory exam
G. Refer to psychiatrist for proper evaluation and management

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 BHETWAL

4. What will you discuss?

● Self-harm sign of emotional distress. If
someone is hurting herself, she may be at
an increased risk of feeling suicidal.

●Self-harm is not a mental illness, but a

behavior that indicates a lack of coping
skills. Those at the most risk are people
who have experienced trauma, neglect or
abuse.

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 BHETWAL

The first step in getting help is talking to a trusted adult, friend or medical
professional, a psychiatrist. A doctor will also recommend therapy to help a
person learn new behaviors, if self-injury has become a habit.
● Psychodynamic therapy focuses on exploring past experiences and
emotions
● Cognitive behavioral therapy focuses on recognizing negative thought
patterns and increasing coping skills

Gently encourage someone to get treatment by stating that self-harm isn’t

uncommon and doctors and therapists can help. If possible, offer to help find
treatment.

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 TIU

5. What is your assessment?

ADJUSTMENT DISORDER WITH MIXED
ANXIETY AND DEPRESSED MOOD

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 TIU

Criteria for Adjustment Disorders

❏ Development of symptoms in response to identifiable stressor(s) within 3
months of the onset of the stressor(s).
■ Received failing score that day
■ Scars and fresh blood on left arm during dinner

❏ Marked distress that is out of proportion to the severity of the stressor,

{ ❏ Significant impairment in social, occupational, or other important areas of
functioning
➢ Subjective distress or impairment in functioning: decreased performance in school
■ Difficulty coping in class

Pp 286-287 American Psychiatric Association. (2013). Diagnostic and Statistical Manual of mental disorders (5th ed.). 25
 TIU
Criteria and History
❏ Stress-related disturbance does not meet the criteria for another mental
disorder and is not merely an exacerbation of a preexisting mental disorder

❏ No psychiatric history

❏ Symptoms do not represent normal bereavement

❏ Once the stressor or its consequences have terminated, the symptoms do
not persist for more than an additional 6 months

❖ Associated with an increased risk of suicide attempts and completed

suicide

Pp 286-288 American Psychiatric Association. (2013). Diagnostic and Statistical Manual of mental disorders (5th ed.). 26
 TIU

Subtype
❖ With depressed mood
➢ Low mood, tearfulness, or feelings of hopelessness
❖ With anxiety
➢ Nervousness, worry, jitteriness, or separation anxiety
❖ With mixed anxiety and depressed mood
❖ With disturbance of conduct
 leads to infringement on others’ rights, or rebellion against normal rules of
conduct.
❖ With mixed disturbance of emotions and conduct
❖ Unspecified (does not fit any of the above)

P.287 American Psychiatric Association. (2013). Diagnostic and Statistical Manual of mental disorders (5th ed.). 27
RULE OUT
BRAVO

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BRAVO

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 BRAVO

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of mental disorders (5th ed.). 30
 BRAVO
● Criterion symptoms for major depressive disorder must be present nearly every
day to be considered present
● Essential feature: Depressed mood or the loss of interest or pleasure in nearly
all activities (at least 2 weeks)
● The mood in a major depressive episode is often described by the person as
depressed, sad, hopeless, discouraged, or "down in the dumps
● Loss of interest or pleasure is nearly always present. Report feeling less
interested in hobbies, "not caring anymore," or not feeling any enjoyment in
activities that were previously considered pleasurable
● Sleep disturbance may take the form of either difficulty sleeping or sleeping
excessively
● The sense of worthlessness or guilt associated with a major depressive episode
may include unrealistic negative evaluations of one's worth
Pp 160-168 American Psychiatric Association. (2013). Diagnostic and Statistical Manual of mental disorders (5th ed.). 31
 BRAVO

RULE OUT: Normative Stress Reactions

● Adjustment Disorder is when the magnitude of the distress
exceeds what would normally be expected or when the adverse
event precipitates functional impairment.
● Normative stress reactions do not usually involve difficulty or
interruption in going about one’s daily routine

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 MOODLEY

6. What are your plans?

●Adjustment disorders are highly treatable

●It responds well with pschotherapy (address the stressor)

●Therapist can work with the patient’s negative thought pattern and irrational
beliefs

●Medication is used depending on the severity of the symptoms

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MOODLEY

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 MOODLEY

Psychotherapy (Talk Therapy)

● It is the main treatment for Adjustment Disorders
● It can be done as an:
- Individual therapy
- Group therapy
- Family therapy

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 MOODLEY

Cognitive - Behavioral Therapy

An approach that helps people

reframe problems and outlook by learning
to identify automatic negative thoughts
and replace them with more realistic ones

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 MOODLEY

Acceptance and Commitment Therapy (ACT)

A mindfulness and coping

therapy that helps people accept
difficulties and reactions, choose
meaningful direction, and take action
to achieve goals

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 MOODLEY

Solution Focused Brief Therapy

An approach that helps people

identify where they want to be and
how they are going to get there

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 ADINNU
Medication
●Benzodiazepines

○Lorazepam and Alprazolam

●Nonbenzodiazepine anxiolytic

○Gabapentin

●SSRI or SNRI

○Sertraline and Venlafaxine

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