NAME: NABILAH BINTI DATO’ AYOB
NIM: 060 100 814
1. PSYCHIATRIC HISTORY
Name : Wan Haliza binti Wan Nan
Age : 32 years 9 months
Sex : Female
Marital Status : Married as second wife with 2 child
Religion : Islam
Educational level : Diploma of Accounting
Address : KM 6, Jalan Kaki Bukit, 01000 Kangar, Perlis
Occupation : Pembantu Tadbir, Jabatan Insolvensi
Source of referral: Klinik Ehsan
Phone Number : 04-9766796
Duration A few days ago (4-5 days)
Patient came because she felt no spirit, unhappy, tired and very sleepy.
HISTORY OF PRESENTING ILLNESS:
The patient complaints started a few days ago, she said she was concern about her
eldest sister who was previously married and now had been divorce. Currently her
sister and the family are living with her under one roof. She mentions that her sister
have schizophrenia since childhood, and that she was really worried about her sister
life. She also mention that she was worried if the same thing will happen to her and
this brought her to feel no spirit, tired and also worried. She was feeling sleepy and
tired even when it is in the morning, she explain that she will sleep from Maghrib
prayer time till the morning and still feel tired. She said even without the medication,
she still feel sleepy and tired.
The patient onset of illness started in 1996 when she was in her early adult age of
19. She was a college student who rented a house in Selayang mansion, she was
having problem with the landlord. The landlord all of a sudden, rented the house to a
group of boys without telling her. The landlord also locks the house door using a new
key and that she can’t come into her house. Because of this event she develop the
symptoms of anxious when in a crowded place and in tense situation, low mood,
sleepless, not stable, loss of appetite, dizzy, and feeling weak in doing activities even
a simple one. She also said that because of the problems she feel like they are animal
that can understand to what she’s saying. She did specify that there is a bird (burung
gagak) speaking to her about her problems and give advice to her. Beside the bird she
also claims that she can talk to the cats as well. She explains that she never had a
rough situation in her life before and that is her first time accounting a problem by
herself. During that time her parent only brought her to see bomoh and ustaz to cure
her but, she said there were no improvement with her condition.
Later in December 1997 after a year with duration of untreated illness, her family
then brought her to see general practitioner from Clinic Ehsan in Kangar to seek a
professional help. She is then being reffered to Psychiatric Department in Hospital
Tuanku Fauziah (HTF). She then has been given medication due to her illness. She
did mention about being hospitalized for a week for her illness but she can’t
remember when it was.
In 2003, she married as a second wife. She married willingly to her husband and
knows that her husband has a wife before her. She was living in Putrajaya and work
there as a government servant. Her husband knows about her mental illness condition
and supportive. She drives from Putrajaya to Kangar back and forth for her regular
After a year in 2004, she was pregnant with her first child. She was very happy to
have the baby. She delivers the baby in HTF, but her baby has to be treated in NICU
for about 3 weeks. She then said she had a suicidal thought at that time, she said she
feel worthless and does not deserve to live anymore. She tries to commit suicide by
overdosing her drugs.
In 2007 she transfers her work to Perlis. She transfers from the Custom
Department in Putrajaya to Insolvency Department in Kangar. She said she had
difficulty to adjust to her new office environment. She has problems to get along with
her colleagues and her boss. This was due to her current condition which her
colleagues did not understand. She often asks for leave and always have medical
certificate for her illness and yet her colleagues did not believe her. They see her as a
normal healthy person that did not need to ask for a leave. She felt unhappy for this
and usually she was alone in the office doing her work and did not talk much during
working period. She felt her colleagues did not like her, and feel going to work is a
burden to her.
She also mentions that her relationship with her husband is not so good. Her
husband currently works in Kuala Lumpur and only came to see her once every two
weeks. When ask about did her husband give her living expenses, she said her
husband did not miss it. But she did mention that she rather her husband did not went
back to Kangar at all to see her, because it just give her burden.
On 2008, she was pregnant with her second child. She mentions that her husband
did not give enough attention despite of her pregnancy. She feels that the first wife
has all of her husband life. She feels she can’t move on anymore and again try to
overdose herself with the medication even when she was pregnant. Despite the
suicide attempt, the baby was delivered normal.
During the period from 2009- Early 2010, she continues her follow up in HTF
and sometimes will come to the psychiatric department to tell her problems. Mostly
her problem evolves around her workplace and family.
Until recently she came to the Psychiatric Department to complain about her
current condition of unhappy, felt no spirit, tired and very sleepy.
She still has both of her parents, who are still married. His father is 72 years old
and her mother is 70 years old. Her mother is also the second wife to his father. Her
father currently not working and his health condition is not good because he were
having diabetes mellitus, high cholesterol and heart problem. Her mother who is also
not working has high blood pressure and asthma. Her relationship with parents are
good, and they are currently living together with the addition of her elders sister
family recently. She did not get along with her eldest sister very well since her sister
suffers from schizophrenia. Her relationship with her second sister is good.
72, DM, Hi Cholest, 70, Hi BP, Asthma
42, Schizo 39, Anxiety 33
FAMILY PSYCHIATRIC HISTORY:
Her eldest sister is currently suffered from schizophrenia. Her eldest sister had suicide
attempts several times but is saved. Her second sister had anxiety problems.
D.O.B : 6 May 1977
Place Of Birth : Kangar
Abnormalities to or at birth (e.g. premature labour) : -
Childhood health/hx of nervous problem:
She stated that she does not suffer any health problem in her early age except for her
Early emotional stress : The illness of her eldest sister.
Age beginning schooling: 6 years old
School attended :
-Sekolah Kebangsaan, Sekolah menengah kebangsaan, College ITTAR
Relationship with peers and teachers:
-She said that she did not care about the environment, she is a loner, always by
herself, did not have any bestfriend during her schooling years, and are not close to
History of truancy or other trouble or difficulty at school: None
Qualifications achieve: Diploma in Accounting
Age leaving school: 21 years
Higher education: College taking Diploma
iii. OCCUPATIONAL HISTORY
As mention earlier she did not enjoy her work. She felt as if it was a burden. Her
colleagues did not like her and she felt that her boss to. She said that her colleagues
often talking about her at the back and saying that she is a liar because she always
asks for a leave.
Previously she work at Putrajaya in Custom Department and then ask for transfer
to Kangar to live with her mother and it is easy for her to come for her follow up in
She always feel tired and sleepy at her work place and did not have any close friend.
iv. RELIGIOUS BACKGROUND
She follows her religion accordingly but sometimes she said she missed the solat.
v. PSYCHOSEXUAL HISTORY
Age menarche : 11 years old
Menstrual Abnormalities: None since she is on her birth control pills
History of pregnancy : G2P2
Sexual orientation : Heterosexual
Sexual physical abuse history: None
Sexual difficulties: None
vi. CURRENT SOCIAL SITUATION
With whom live :
-Living with both her parents, her eldest sister and her child, her children
Occupational and financial status:
-Still working as a government servant and she stated her salary is not enough to
support she and her family
Nature and suitability of accommodation:
`To many people living in her house, she felt uncomfortable with it.
Hobbies and social interest: Watching Tv, Listening to the radio
PAST MEDICAL HISTORY
Physical disorder: None
Medication side effect: Sleepy, she felt as her head blank after woke up from her
sleep after taking medication.
Metabolic illness: (heart failure/ kidney/diabetes/hypertension)
-She said she had diabetes in her pregnancy but now she did not do any regular
checkup and did not know her condition currently.
PSYCHOACTIVE SUBSTACE USE
Alcohol : None
Tobacco : None
Illicit drug abuse: None
2. MENTAL STATUS
i. PERSONAL IDENTIFICATION
Wan Haliza is a 32 year old Malay woman, she appear as her age is. She was fairly
groomed, wearing a scarf that suit with her Baju Kurung. She did not wear any make up
and looking very tired and sleepy.
ii. BEHAVIOR AND PSYCHOMOTOR ACTIVITY
She sits normally but put her hand on the desk to hold her heads up as if she was really
iii. GENERAL DESCRIPTION
Overall she is well dress and cooperative during the interview even though she is tired
She at a normal rate and in normal quantity, no neologism detected throughout the
interview, she speaks in “utara/Perlis” dialect. The form is also ok.
c) MOOD AND AFFECT
When asked about her feeling today she said she feels tired and no spirit. Her mood was
slightly depressed. Her mood is appropriate with the thought content.
Her affect appears appropriately to what she is saying, and changes when it is sad or
happy but seem restricted to her restless state at the moment.
d) THINKING AND PERCEPTION
i. FORM OF THINKING
The patient productivity of thought is good. She answered spontaneously and often
elaborate the answer
Continuity of thought
Patient answer the questions and are goal directed.
ii. CONTENT OF THINKING
iii. THOUGHT DISTUBANCE
Currently patient does not have any delusion. In previous history, patient use to have
grandiosity delusion. She said she was able to make anything she sees as her own
thing. For example if she sees a book that belongs to her friend she will use her power
to make it hers instead.
Ideas of references and ideas of influence: None
iv. PERCEPTUAL DISTUBANCE
Hallucination and illusion:
Currently she did not experience any hallucination. But previously, the patient use to
have hallucination that she could talk to a bird specifically (Burung Gagak) even if it
is not there. She claims that the bird can understand her feelings and help her. Besides
the birds, she also said that she can talk with animal. This is a second person
hallucination and its happen that she had auditory and visual hallucination as well.
Depersonalization and derealization: None
v. DREAM AND FANTASIES
Dream : -
The patient appears alert and co-operative.
She is orientated to time, place, and person.
iii. CONCENTRATION AND CALCULATION
Patient is able to recite months in a year backwardly and also can count the subtraction
of seven started from 20-7 with no difficulty at all.
Remote memory : Good
Recent past memory: Good
Recent memory: Good
Immediate retention and recall:
Memory is very good for immediately recall of all three object ‘kotak, pokok, pasu’.
She also can recall all of it even after 5 minutes.
v. FUND OF KNOWLEDGE
Good. Patient recalls the neighbor of Malaysia such as Thailand, Indonesia, Filipina,
Laos, Cambodia and Singapore. She also know who is the recent Prime Minister which is
Datuk Najib bin Tun Razak.
vi. ABSTRACT THINKING
Good. When asked about proverb of “Alang-alang menyeluk perkasam, biarlah sampai
ke pangkal lengan” she can interprets it correctly.
Good. Intellectual insight. Awareness of being ill and that the symptoms/failures in social
adjustment are due to own particular irrational feelings/thoughts; yet does not apply this
knowledge to the current/future experiences.
Social judgment: Good
Personal judgment: Good
3. FURTHER DIAGNOSTIC STUDIES
Physical examination: -
Additional psychiatry diagnostic:-
Interview with family members, friends or neighbor:-
Psychological, neurological or laboratory test as indicated:-
4. SUMMARY OF FINDINGS/ RESUME
Patient has had previous psychiatric condition starting late 1996. She was in duration of
untreated illness for about 1 year. She was referred to HTF in 1997 because she develop
the symptoms of agoraphobia, depressed, insomnia, labile mood, loss of appetite,
headache, and lethargic. She also suffers auditory and visual hallucination. She claim that
she had grandiosity delusion in her age of 14. After the born of her 1st child (2004) she
had attempt a suicide by taking overdose medication and again she commit suicide when
she was pregnant her 2nd child (2008). She feels worthless and hopeless at that time and
her husband is living in Kuala Lumpur. Currently she still under her medication from her
illness and came to HTF later today because she feel lethargic, restless, sleepy and
unhappy with her life.
AXIS I : Schizophrenia Paranoid Type
AXIS II : Introvert Personality
AXIS III: None
AXIS IV: Problems with living condition, family problems of husband, eldest sister and
have to take care of her parent as well, workplace problems especially with colleagues.
AXIS V: GAF 71-80
6. DIFFERENTIAL DIAGNOSIS
a. Schizoaffective Disorder
b. Bipolar disorder
FACTORS GOOD POOR
FAMILY HISTORY Elder sister with
ONSET Insidious and early onset
SUPPORT Good family support
MARITAL STATUS Polygamy married
COPING WITH STRESS Poor
Overall prognosis is poor.
8. TREATMENT PLAN
Non Pharmacological :
o Psychoeducation for the patient and family
o Family therapy
o Individual psychotherapy
o Risperidone (0.5 – 8 mg) per day