Weekly post-graduate case presentation date: 2000 venue: dept of psychiatry, USM

1. CASE PRESENTATION
Marital Disharmony
I thought the day would be dry till the end, who would expect heavy rain at noon.
KU SANGKA PANAS HINGGA KE PETANG…
RUPANYA HUJAN DI TENGAH HARI…

2. Identification Data
 Mrs. S, 43-year-old Malay housewife
referred from gynecological clinic on
July 9th, 2000.
 The spouse: Mr. B, 46-year-old
executive officer.

3. Chief Complaint
 Marital disharmony
since March 2000
i.e. After Mrs. S
learned the husband
second marriage

4. History of Present Illness
 March 2000 - a friend
told her about his 2nd
marriage that
happened 3 months
earlier
 Confronted him,
husband vehemently
denied - said she was
only a close friend

5. History of Present Illness
 Mr. B finally admitted
 Marriage was conducted in Thailand
 Second wife profile: 42 years old
divorcee with 4 kids from previous 4
marriages, businesswoman.

6. History of Present Illness
 Family members &
friends were
surprised.
 What went wrong?
 What so special
about the second
wife?
 First wife was heart
broken & tearful

7. Why heart broken & tearful?
 Felt betrayed &
cheated
 Unappreciated
sacrifices
 Insulted & rejected

8. Betrayed & Cheated
 In the early days of their married life,
husband had promised to be faithful,
would never love a woman except her.
 Husband often joked about getting a
second wife.
 Exemplary couple in others’ eyes
 Marriage behind her back

9. Unappreciated Sacrifices
 Had played major parenting roles - almost
single handedly in educational,
disciplining, daily needs of children.
Husband always busy, frequent outstation
 House chores - gender division. She was
full-time housewife whereas hubby the
sole provider.
 Never ask expensive items

10. Insulted & Rejected
 Profile of second wife. Why her? Why
not a young never married girl?
 An officemate of Mr. B once asked him
the reason. His metaphor was “there
was an unoccupied space in my heart
and I was merely filling it up”

11. Lowered self-esteem & Jealousy
 Those feelings made
her self-esteem
lowered (tearful,
lacking in her
femininity etc),
shame (preferred to
be in the house etc)
and jealous

12. Jealousy
 Demanded unequal night allocation i.e.
First wife 4 nights & second wife 3
nights in a week.
 Expressed disgust about husband
intimacy in public (esp. In office)
 Threw tantrums 3 times - 1) very quiet
during meal 2) she saw loose thread on
car seat 3) demand him to swear

13. How Can I Beat her?
 Sexier: Ask husband to buy aerobic
clothes & joined aerobic class
 Successful businesswoman: A female
friend who was a higher ranking in that
multilevel marketing company offered
to train her better than the “madu”.

14. One is not enough but I shall be fair
 It was a man right
when you desired
another one and you
were
materially/sexually
capable and be fair
amongst them.
 Business opportunity
 To guide her

15. His reaction to her complaints
 Withdrawal:
Disappearance
without notice/news
for 3 times - 7, 9, 26
days
 Communication:
Monosyllabic, quiet,
resorted to writing
notes

16. Her Conflict
 To preserve the
marriage: financially
dependency, for the
sake of children
 In favor of
separation:
overwhelming
jealousy

17. Reaction of Others
 Mother-in law: tearful
 Other in laws: aghast, giving unsolicited
advises (for him: reconsider his
marriage, for her: be patience, accept
the fate)
 The children: anger, shame, hatred

18.  Eldest son: “I would
have done things, If
I were not reminded
him as my father”
 Younger son: “I want
to see her whether
she is prettier than
my mom”
Quotable Quotes
 Elder daughter: “I
will never marry,
unless I met
someone like my
father”
 Younger daughter:
frequent ill, looking
for daddy, school
refusal, reared
hamster.

19. Other Symptoms
 Initial insomnia, reduced appetite
 No anhedonia, suicidal thought (passive
or active), loss of weight.
 Social-occupational functioning normal
 No psychotic symptoms

20. History of Previous Illnesses
 Medical: Nil of significance
 Surgical: Appendectomy July 1999
 Psychiatry: Nil of significance
 Obstetric: MRP during fourth childbirth
 Gynecology: Endometriosis diagnose
after incidental HPE findings, currently
on OCP

21. Menstrual History
 Menarche at 14 y
 28-30 d regular
cycle
 Dysmenorrhea
 2 y ago, 15 d
menstruation
 No PCB, IMB,
dyspareunia

22. Personal History - occupation
 Mr. B: secondary school education, at
22 y clerk RM280/month, now earns
RM5000/month.
 6 ppl in department (5 male, 1 married
female), covering east coast

23. Personal History - social act
 Mr. B: a loner,
introverted, prefer
solitary activity, not
playing football etc.
 Mrs. S: homely type,
always accompanied
by him when outside

24. Personal History
 No premarital relationship
 ? Extramarital relationship 1) brief crush
(less than 3 months) to 2 divorcees 2)
very close to female subordinate -
frequent outstation together, once
telephoned him at 3 a.m.

25. Marital History
 Love marriage, initial resistance from his
grandfather.
 She was 19 and he was 22.
 She was submissive and dependent wife
 4 children: 23 boy a diploma holder, 21
student girl, 15 boy form 3, 13 girl form1

26. Relationship within Family
 Mr. B: seldom talked
to children.
 All needs conveyed
through Mrs. S
 After the discord,
children took mother
side

27. Religious Background
 Mr. B: daily prayers -
procrastination, not
fluent in reading
quran, once joined
Islamic discussion
group but only for
short while - sensitive
to comments
 Mrs. S: average
local Malays.

28. Habits & Addiction
 Mr. B: light social
smoker.
 Non-drinker, non-
gambler
 No other substance
use
 No specific hobby
 No addiction
 Hobby: reading

29. Family History
 Mr. B: second in birth
order, most successful
financially
 2 male siblings: one
policeman in KL had
extramarital affair,
another get caught
for close proximity
 Grandfather was
polygamous
 Only child of same
parents.
 Parents divorced
when she was 5 y
 had one half-sister
of same mother.

30. Current Social Situation
 Stays in semi-detached house
(estimated value RM 50 thousand)
 Husband owns a car & motorbike
 Monthly expenses supported by him.

31. Mental State Examination
 General description: Neat, middle social
class Malays, she wore headscarf
 Mood & Affect: sad, either tearfulor
angered depended on topics, broad-
ranged appropriate affect
 Perceptual disturbances: None
 Thought process: Normal flow, no
abnormal content

32. Mental State Examination
 Sensorium & cognition: Orientation,
concentration and memory were
normal. Information & intelligence
average.
 Judgment: Test - intact. Social -
affected (distrustful to men in general)
 Insight: present
 Reliability: okay

33.  Physical
examination: nil of
significance
 Laboratory
investigations: nil of
significance

34. Summary
 43-year-old Mrs. S was married to 46-year-old Mr. B
for the past 24 years. Marital disharmony started 4
months ago when Mrs. S found out that Mr. B had
married 42-year-old divorcee. Mrs. S felt betrayed,
unappreciated, ashamed, and insulted by his second
marriage. Mr. B defended his second marriage by
saying that it was his right and he would treat them
fairly. He cited religious reason for marrying Mrs. X
such as to guide her to proper Islamic pathway and
avoiding adultery as well as to fulfill his ambition to
venture into business world.

35. Summary
 Jealousy drove her into interrogating his whereabouts,
making wild allegations to Mrs. X and quarreling with him.
Mr. B reacted by avoiding her further, exemplified by him
disappearing without news for days as well as minimal
direct conversation while at home. The relatives were
asking him to reconsider his second marriage i.e. to
divorce Mrs. X but Mr. B was determined to uphold his
decision. The children were ashamed of their father. The
youngest daughter manifested transient school refusal.
Mrs. S self-esteem was lowered and she did felt sad.
However, there was no anhedonia or definite biological
symptoms of depression.

36. Summary
 Mr. B was quiet, introverted and dislike
strong personal critics that he apt to avoid
them. In the workplace, he was closer to
married female subordinate although there
was no concrete evidence of extramarital
sexual relationship. In the past, he had
unexpectedly fell in love, albeit briefly, on two
occasions with almost middle age multi-
parous divorcees. Two of his siblings had
history of extramarital relationship.

37. Summary
 In the past 2 years, the frequency of
sexual intercourse was reduced by Mrs.
S gynecological problem. It was even
more infrequent after the marital
conflict. Mrs. S also found her desire for
him was lacking. There was no other
sexual symptom.

38. Provisional Diagnosis
 Axis I: 309.0 Adjustment
disorder with depressed
mood
 Axis II: V71.09 No
personality disorder
 Axis III: 617.9*
Endometriosis
 Axis IV: Marital discord
 Axis V: GAF = 91 (highest
level past year) GAF = 65
(current)
 Axis I: V61.20 Partner
relational problem
 Axis II: 799.9 Deferred
diagnosis.
 Axis III: None
 Axis IV: Discord with
immediate family
members
 AxisV:GAF=91 (highest
level past year) GAF =
75(current)

39. Differential Diagnosis
 296.21 Major depressive
disorder, single episode, mild.

40. Formulation
 Forty three years old Mrs. S and 46 years old Mr. B presented
with marital disharmony for the past 4 months. Mrs. S was
angered and depressed when she knew the husband had
secretly married another woman.
 The provisional diagnosis of Mrs. S was 309.0- adjustment
disorder with depressed mood. The emotional symptoms
developed within 3 months after the onset of the stressors i.e.
marital discord (Criterion A) and the clinically significant stressor
caused notable impairment in her personal relationship with Mr.
B (Criterion B). In addition, the symptoms do not represent
another specific Axis I disorder or are merely an exacerbation of
preexisting Axis I or II disorder (Criterion C) and are not part of
bereavement (Criterion D). As for Criterion E, it is too early to
decide as the stressor is still going on.

41. Formulation - differential
 The differential diagnosis was 296.21 single episode
of mild major depressive disorder. She had depressed
mood indicated by her own subjective report and
observation by others e.g. appeared tearful (Criterion
A1), loss of appetite though no weight loss (Criterion
A3), frequent initial insomnia (Criterion A4), and
feelings of worthlessness (Criterion A7). Altogether,
there were 4 out of 9 symptoms necessary to
diagnose a major depressive episode. Hence, it was
unlikely to be a major depressive episode, which
requires at least five symptoms.

42. Formulation - precipitating
 The couple Axis I diagnoses was
precipitated by Mrs. S learning
about Mr. B second marriage.

43. Formulation - predisposing
 Mrs. S was predisposed to depression in view of her total
dependency for financial support and the threat of losing
the husband. History early parental divorce.
 While Mr. B was predisposed to marrying another woman
because of Mrs. S endometriosis with its resultant
prolonged menses and less opportunity for sexual
intercourse, previous history of unexpected crush on
divorced women and his avoidant personality. His
personality was as such that Mr. B did not have a
meaningful and confiding relationship except in the
context guaranteed acceptance in married life.

44. Formulation - perpetuating
 The perpetuating factor was the
impaired communication between the
spouse that hampered correction of
misunderstanding between them. Self-
defeating behavior such as purposely
tried to make the husband jealous
served nothing but to aggravate the
marital discord.

45. Management
 Biological: pharmacotherapy e.g.,
antidepressant, sedative-hypnotics
 Psychosocial: marital therapy

46. Indications
 Marital therapy is indicated
when it is requested by a
couple, married or not, with
disharmony in the relationship
who either are committed to
maintaining the marriage or
the relationship or have
decided on divorce or
separation and want help in
facilitating that end.

47. Objectives
 The general objective of the therapy would be to minimize
the emotional distress experienced by her in particular
and to a certain extent the younger children. The decision
whether to maintain the marriage or to end it was up to
the couple to choose. The therapist role was to help
demonstrate the advantages and disadvantages of both
options.
 The specific objectives include improving the couple
communication and providing possible explanations for
some of the maladaptive behavior.

48. Surah An-Nisa (The women) 4:3
 “And if you fear that you shall not be able to deal
justly with the orphan-girls, then marry (other)
women of your choice, two or three, or four but if
you fear that you shall not be able to deal justly (with
them), then only one or (the captives and slaves)
that your right hand possess. That is nearer to
prevent you from doing injustice.”

49. Kelantan Islamic Family Law
Enactment 1983
 Kelantan Islamic Family Law Enactment 1983, s.19
provide that no married man shall marry another
women unless he has obtained a prior consent of the
kadi without which his marriage shall not be
registered.
 According to Raja Rohana (1991) such a brief
provision is inadequate, hence the family law
enactment of Negeri Sembilan, Malacca and the
Federal Territory contain a detailed and extensive
section on polygamy.

51. Type of Jealous Behavior
 Jealous behavior may take many forms and be
directed toward either the partner or the rival.
Isolational behaviors – for example, withdrawal,
withholding, or fight evasion – which do not
enhance the relationship and which interfere with
resolution of problems. Antagonistic behaviors –
quarreling, intrusive interrogation, or taking
revenge, for example – maintain contact between
partners, though in a negative way that might
neither enhance the relationship nor favor
resolution.

52. Contraindications
 .Kadis and McCleadon (1995) describe four
relative contraindications of marital therapy
that predict poor response, namely 1) there is
lack of commitment to the relationship, 2)
one partner is already involved with another
person, 3) there is inability to control the
hostility or anxiety that is generated, or 4)
the therapist is unskilled in marital therapy or
couple therapy.

53. THANK YOU
 The captain and the co-
captain should leave the
sinking boat last
PRESENTER:
Dr Zahiruddin Othman