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Department of Psychiatry and Behavioral Medicine

Philippine General Hospital


University of the Philippines Manila
The Health Sciences Center
Taft Avenue, Ermita, Manila
PHIC Accredited Health Care Provider
ISO 9001:2008 accredited

Grand Rounds Case Protocol

Submitted by: Maria Arla Andrea G. Carasco, MD

General Data: Lucas is a 51 year-old male, married, self-employed, high school and ministerial

school graduate, former minister of an international Christian denomination religion that originated

in the Philippines, father of 3, living in Laguna.

Sources of information and reliability: Patient (poor reliability), Wife (fair reliability)

Chief complaint: pinapatingnan ng (name of Christian religious denomination) (patient)

History of Present Illness:

20 years prior to consult, Lucas was working in Aurora as a minister of an international

Christian denomination religion that originated in the Philippines when he met Erica, the 16 year-

old daughter of a deacon in the locale where he was assigned. Ericas father entreated Lucas help

to get her back after she went away with her non-church member boyfriend, and they were able to

track her down and bring her home. Of Erica, he thought, May nangyari na siguro. Hindi na siguro

virgin. When Lucas met Erica, he thought that she had a pretty face and was immediately

attracted to her. He denied having recurrent, intense sexually arousing fantasies and sexual urges

about Erica and only conceded that he found her physical features attractive and thought about her

only when he saw her. Afterwards, while Lucas was working with Ericas father on a mission, and

while his wife and 2 sons were away visiting her parents in Cavite, Lucas was invited by Ericas

family to stay with them as it was raining hard and it would be difficult for him to go home. That

night, Erica allegedly came to his bed and fanned him, as there was no electric fan where Lucas

was staying. As she lay beside him on the bed while fanning him, Lucas thought that she was there
because she wanted to be with him. He felt excited and sexually aroused at the time and thought

that he was being given the opportunity to act on his desires for Erica. He started hugging and

kissing her, and when she did not struggle and let him kiss her on the lips, his sexual excitement

increased and he thought, Gusto niya. He thought that Erica wanted to have sexual intercourse

with him, too, because she did not resist him and did not make a sound when he removed her

clothing and had intercourse with her without using contraception, after which Erica put her clothes

back on and slept with him the rest of the night. Lucas felt pleasure and satisfaction at the time and

did not feel any guilt or regrets about what he had done. It was only on the next day, when he woke

up that he felt scared that people will find out what happened and tell his wife or his superiors and

he will be reprimanded, so he left early for home without waking up Erica and her family, and since

then avoided them all. After 2 months, the district minister called him and his wife and asked Lucas

if he had sexual intercourse with Erica, to which Lucas admitted to doing so but insisted that what

happened between them was consensual. Lucas was told that Ericas parents reported that he

raped her and got her pregnant and was claiming that he was the father of her child, whom he

refused to believe and instead, insisted that the father was Ericas boyfriend. Because of this

complaint, he was fired from being a minister and ex-communicated from church. He and his family

were told to leave Aurora immediately and he was forbidden to contact Erica again but no legal

case was filed against him. Lucas felt intense regret at what he had done because of the painful

consequences of his actions such as the loss of his status in the church, his wifes hurt and

disappointment in him, and the loss of his salvation. He asked his wife to forgive him, and she did

because Lucas told her that he only did it because of temptation, blaming Erica for tempting him

and causing him to stray from his marital vows, and in the end, promised her that he would never

do it again. Lucas also believed that Ericas parents purposely let him sleep with her because they

knew that she was already pregnant with her boyfriend and wanted him to take the fall. He also

believed that his enemies in their locale influenced Ericas family to report him so that he will be

dismissed from his ministerial duties.

He could not do anything to overturn the churchs decision at the time, so he and his family

went to Laguna to live with his in-laws for 2 years. He was sad about what happened to him and

blamed himself for being weak in the face of temptation, but did not let himself think about it and
did not talk about it with his family. He immersed himself in work by opening a sari-sari store and

working as an insurance salesman, intent on providing for his family even though he was not a

minister anymore. He was proud of attaining a perfect score in the licensure exam and was happy

when his company offered to send him to Switzerland for managerial training, but turned it down

because his wife did not want him to go overseas.

As he was becoming successful as an insurance agent, he learned from a former colleague

that he might be reinstated if he was able to get a letter of forgiveness from Erica and her family.

He told his wife and his mother about this and on his urging, they actively pursued the matter,

personally going back to Aurora to talk to Erica and her family and finally getting a letter of

forgiveness from them, which Lucas submitted to their church and used to have himself reinstated.

When he was finally given his assignment in Catanduanes, he immediately left his job without

collecting his final commission and went back to his ministerial work because he believed that if he

died not fulfilling his ordained mission from God, he would not be saved according to the teachings

of their church.

In the interim, he continued serving as a church minister at several locales in the country for

8 years with no reported incidences of sexual offending. He fulfilled his duties to oversee worship

services and increase his congregation. Though he was friendly and inviting to everyone, he

interacted more with female teenagers because he felt more comfortable with them and treated

them like friends, teasing them and joking around with them. While doing so, he made enemies in

almost every locale he was assigned to where he was not successful, from a barangay captain

whom he believed was threatening his converts, to a rival minister from another religion whom he

believed was defaming his church.

11 years prior to consult, he was assigned to a locale in Catanduanes and met Jenna, a 14

year-old female church member, who was active in church and helped out in the renovations that

Lucas had started. Lucas noted that he was attracted to her because she had a pretty face and

body, and believed that she was attracted to him, too, because she was always smiling and

friendly towards him. He felt happy when she would tease him and tell him that he was handsome,

and believed that she was flirting with him, which aroused him and made him feel like kissing her.

He had known Jenna for a month when his wife left to visit her parents again, and while she was
away, he felt his growing attraction come to a head as he saw Jenna alone in the sound room of

their church. He felt an intense desire to kiss her on the lips and when she passed in front of him,

he held her arm and kissed her. He thought that Jenna was amenable to him kissing her because

she did not turn or push him away as he was doing so, and was only surprised but not objecting to

his advances. After kissing her, Lucas felt happy and satisfied and let her go, and Jenna left

immediately. Lucas was not aware how Jenna reacted to what he did and believed that he did not

do anything harmful as it only a kiss. Unbeknownst to him, the church caretaker saw him kiss

Jenna and immediately reported him to the district minister. He believed that Jenna did not want to

file a complaint against him and even wanted to retract her statement confirming what happened,

but that the caretaker allegedly threatened his supervisor that he will be the one ex-communicated

if he will cover up what happened. He was again dismissed from his ministerial duties but this time

was allowed to continue being part of the church.

He and his family went home to Cavite and lived with his parents. During this time, he

resigned himself to the thought that he did not deserve to be a minister because he could not break

away from temptation. He again poured all his effort in working for his family by selling cooking oil

and pirated DVDs because he did not want his family to experience the poverty he experienced as

a child. His father had poor health at the time, and on his deathbed, entreated Lucas to find a way

to get his position back and become a minister again. He sought out the help of his classmate who

had a high-ranking position at the central office of their church and advised to get a letter of

forgiveness from Jenna and her parents, with his classmate giving him financial assistance to do

so. He went back to Catanduanes and was able to get the letter and forward it to the central office.

In a matter of months, he was reinstated as a minister and assigned to several locales in

Camarines Norte and Masbate. He spent the next 6 years fulfilling his ministerial duties

2 years prior to consult, he was assigned to a remote locale in Masbate. Patient felt

attracted to several adolescent females in the locale, several of whom he was beginning to

indoctrinate. One of them was a 12 year-old girl, Lily, whom he started training as a track and field

runner as part of their locales delegation to their churchs provincial sports fest. He had known Lily

and her family for 3 months and was friendly with her parents whom he was indoctrinating, even

helping them out financially when they were in need. He began feeling attracted to her the more
that he spent time with her. She was tall for her age and Lucas saw her as matured na ang

katawan. He started kissing her goodbye on the cheek upon leaving their home, and when she

did not turn away from him and also kissed him goodbye on the cheek, it excited him and

increased his attraction to her, thinking that she was also attracted to him because she was being

accommodating and friendly. He started becoming sexually aroused when they would accidentally

touch and especially when he would kiss her. When the time to go to the sports fest in Masbate

City came, he felt excited and nervous because he knew he would have the opportunity to be

alone with Lily, and was a little scared of what can happen. At the last minute, Lucas asked his wife

to come with them but she refused as she had just travelled all the way from Manila to see their

son. Lucas decided to go ahead with his plan to go to the sports fest alone with Lily and 3 other

female athletes, a 14 year-old girl and two other 18 year-old girls. When they arrived at Masbate,

Lucas rented a room in a hotel, thinking that he and the 4 female teenagers can leave their things

there before going to the sports fest, and eventually spend the rest of the day there. Lucas denied

that he had specific plans about what he wanted to happen in that hotel room but admitted that he

booked it because he thought he would enjoy staying there with the girls. After the track and field

event, Lucas went back to the hotel room with Lily first while the other 3 were still finishing up with

their games. When they were alone in the hotel room, Lucas tried to kiss Lily on the cheek but she

turned away from him and refused to let him kiss her. Lucas was surprised, thinking that she would

not refuse him because she used to let him kiss her goodbye for the past month, so he stopped

and tried to joke about it with her, saying that Lily was being masungit. The other 3 girls arrived

soon after and they went home. After the sports fest, the parents of Lily and the other girls filed a

complaint against him with the district minister. The district minister told him that according to Lily,

he tried to rape her while they were alone in the hotel room, and because of this report, he was

again being dismissed from his duties as a minister. He repeated his previous efforts to get himself

reinstated, however, this time around, he was told to seek psychiatric clearance before the church

can decide to let him get back to his ministerial duties.

He reported having depressed mood continuously for a month after he was dismissed but

denied having other depressive symptoms such as loss of appetite, anhedonia, feelings of

hopelessness or excessive guilt and suicidal ideations. However, though his mood lifted after a
month, he reported that he had persistent feelings of sadness over the next 2 years especially

when his family would inquire about when he will go back to being a minister. He would feel

slighted whenever his family would mention how their life had changed immensely since he was let

go from the ministry. He had difficulty sleeping and spent most of his time online, and even joined

an online e-loading business, an occupation that he does not take pride in as he believes he is not

doing the work that he was ordained to do. He complained of having low energy and of gaining

weight. He finally sought consult at PGH Out-patient Department with the intent of getting

psychiatric clearance to be able to come back to his work as a minister.

Review of Systems:

(+) dizziness (-) weight loss (-) fever (-) nausea/vomiting (-) dyspnea (-) orthopnea (-) chest pain

(-) palpitations (-) dysuria (-) blurring of vision (-) headache

Past Psychiatric History:

No previous psychiatric diagnosis and treatment.

Past Medical History: (+) asthma (+) hepatitis (+) Hypertension (-) PTB (-) DM (-)testing for STI

Family Medical History:

- behavioral changes after head trauma

- heart disease

- congenital cyst, left eye

- deceased

- hypertension

- bronchial asthma
Family profile:

Romulo Lucas father was a hardworking, simple man who worked as a farmer to provide for his

family. He was strict and employed corporal punishment towards his children whenever they do

anything wrong. Though he had financial hardship all his life, he taught his children never to steal

from anyone and instead earn an honest days work through their own efforts. He converted to

their Christian denomination religion after Lucas was converted and was a devout member of the

church until his death.

Edna Lucas mother is also a devout church member who also converted after he converted. In

her younger days, she worked several jobs to provide for their family but due to poverty she and

her husband left their children under the care of her mother when Lucas was 11 years old. She and

her husband went home to Masbate to farm but unfortunately they were not successful and instead

went home to their children and tried to make ends meet. She was able to have a more

comfortable life after Lucas became a minister and is now concerned about when Lucas will go

back to his former position.

Lorna She became his wife when he was about to become a minister. Lucas chose him over his

other girlfriends because he believed she was the most suitable to become the wife of a minister

since she was 2 years older than him and was more mature than his other girlfriends.

Tony Lucas oldest brother has an undiagnosed behavioral problem since he was 12 years old

after he had a head injury. He has not been heard of since he left home at the age of 17.

Queenie Lucas oldest sister became his primary caregiver during his early childhood because

both of their parents were hard at work. Lucas thought that she was pretty and attractive, and that

she had many suitors. Lucas had a close relationship with her while they were growing up, but

when she had a family of her own they eventually drifted apart.

Romy Lucas parents treated his other older brother as someone who could not do heavy work

due to his congenital cyst on his left eye, though he was able to finish high school and have a

family of his own. Romy also converted, same as the rest of their family.
Anamnesis:

Patient was born full term via normal spontaneous delivery, with an unremarkable perinatal

course, no noted maternal illness and no fetomaternal complications. He is the youngest of four

children. He had no noted developmental delays during infancy and early childhood. His primary

caregiver was his mother until 4 years of age. Lucas does not have any memories of his early life

and does not know any stories from his mother about how he was as an infant and toddler. At age

4, his father took him and his siblings with him to Masbate where he found work as a plumber while

his mother stayed behind in Pasig to continue working as a factory sewer. His older siblings

became his caregivers as his father was working, and even when their mother followed them, his

oldest sister still took care of him as his mother also continued to work. He was a shy and quiet

child who interacted mostly with his siblings and a few playmates.

He and his siblings relocated several times, first when he was 6 years old to Ticao Island

which he considers as the happiest time in his childhood because they were all together as a

family and even if they lived simply, their life was peaceful and he was able to go to school

regularly. When Lucas was 8 years old, his oldest brother Tony had a head injury and fractured his

skull, after which he was noted to have episodes of aggression and disorganized speech, which

would spontaneously resolve and recur intermittently. He was not brought to a doctor and their

family learned to get used to his behavioral changes. At age 9, Lucas stopped going to school

because his parents did not have enough money to send all of them. At age 10, he was able to go

back to school and started selling vegetables grown in their backyard so he could earn for himself.

At age 11, his parents brought him and his siblings to their maternal grandmother in Cavite, telling

them that they were only going to be gone for a month so they can earn money by farming.

However, his parents did not come back and was not able to give them financial support for 6

months. Tony, who was 17 at the time, left home and started working in a piggery and was not

heard from again. Lucas again stopped going to school along with Romy. Queenie continued to go

to school in order to graduate from high school while Lucas delivered pan de sal and newspaper so

that they would have money for food. He felt sad and often pitied himself and his family because of

their situation in life. He also felt unsafe in their neighborhood because there were gangs and gang
wars, though he denied ever involving himself with them and denied ever stealing and getting into

other criminal activities. When his parents finally came back to live with them after 6 months, his

paternal grandmother visited them and took him to Quezon to stay with her for almost a year. Upon

going back to Cavite, he found that his family had relocated to Laguna.

When Lucas was 12 years old, he went back to school and started feeling attracted to a girl

in his class and started experiencing sexual urges but did not know what to do about them, as his

parents did not talk to him about sex and he had no one else to talk to about it. During this time,

Queenie who was then 18 years old started working as a hostess in a club so she would have

money for college. His sister brought him after school to the club where she worked so that she

had someone to go home with. Before operating hours, he would sweep and clean the club to earn

a little money. While he was there, he saw women kissing and sitting on their customers laps,

which excited and aroused him but also made him uneasy because he never saw his parents do

those acts in front of him. He did not fully see and understand what was happening inside the club

but learned that it was something that was not done outside and knew intuitively that there was

something wrong because he was not allowed to enter the club during operating hours from 6pm-

12 midnight. He overheard the conversations of the adults around him and learned that women

who worked there contracted diseases when they go out of the club with their customers, and

because of that, he believed that these women were dirty and dangerous. He was scared of them

but believed that Queenie was different because he had never seen her do what the other women

did. However, he also started feeling scared and protective of her, always tagging along when men

approached her. At one point, Queenie left the club with a middle-aged Chinese man and brought

Lucas with her when they checked into a hotel room. Lucas remembered feeling excited to be

spending the night in a hotel room for the first time, but was also nervous because he did not know

what they were going to do there. He eventually felt at ease when he saw that the man that

brought him and Queenie there looked clean and had nice clothes, and was gentle when he put his

arm around him to guide him into the room. Until the present, Lucas maintains that his memory of

that night was vague because he was so sleepy so he could not remember if he slept on the couch

while the two were on the bed, or if he slept on the bed while the two lay on the carpet. He only

remembered falling asleep as the man was teaching his sister Mandarin and waking up hours later
in the early morning not being able to breathe, scared, wheezing and calling for his sister. He

denied remembering what he saw when he woke up and only remembered that the man wanted to

bring him to the hospital but his sister refused and only waited for his asthma attack to pass. When

he felt better, Lucas and his sister went home. Because of what happened, his impression was that

the Chinese man was nice and caring, different from the other men he saw in the club. He did not

see the man again until 2 months after when Queenie found out the man had gotten her pregnant,

and when she told him, the man went to their parents and told them that he would provide for his

sister and their child. Queenie stopped studying and working at the club, which made Lucas feel

relieved and made him admire the Chinese man for being good to his sister. After Queenie gave

birth, Lucas helped in taking care of his nephew for a while until they moved out and Queenie

started living with another man and spent less time with their family.

With Queenie gone, Lucas continued school and graduated from elementary and continued

into high school as he and his family moved back to Cavite where his father opened a tailoring

shop.

At age 14, he met several gay hairdressers in a parlor next to his fathers tailoring shop. He

enjoyed their company and the attention they gave him because they often joked around him and

even gave him food. They would tell him how handsome he was, and cut his hair for free and even

shape his eyebrows. He denied that they did anything else to him other than that. When Romulo

found out about this, he got angry and forbade him to see them because he it seemed to him that

Lucas was becoming effeminate and told him, Baka mahawa ka sa kanila, baka maging bakla ka

din. His father stopped renting out the parlor space to them, which made Lucas feel sad because

he never saw them again.

He continued with his high school studies and excelled academically. He had his first

girlfriend at age 16, a 15 year-old classmate whom he shared his first kiss with. He stopped going

to school for a year in his 2nd year in high school after his Filipino teacher scolded him for

allegedly correcting him in class, and enrolled again the next year. However, he transferred to

another school for 3rd year, and there, he became involved in a fraternity and even established his

own fraternity with his friends. He became involved in fraternity violence, though he still excelled

academically. When his adviser told him that he would not get any honors since he was a
transferee, he refused to take his exams but still got 3rd honors, which he did not claim at the end

of the year. He also became active in the barangay youth activities and was sent to dances in

several barangays and had numerous girlfriends in each barangay. At age 20, he first had sexual

intercourse with a girlfriend whom he knew had already had sexual experience. Though he had

many girlfriends, he reported that he only ever had 4 sexual partners. He also learned to smoke

cigarettes and drink alcohol during parties or dances.

He was unable enroll for his 4th year in high school because his father went into hiding to

escape their town mayor who had his father beaten up because he allied himself with the mayors

enemies. Their family travelled to a remote town where they farmed to sustain themselves. He was

enjoined by the local New Peoples Army to train with them and assassinate the mayor. While he

was awaiting the order to carry out his mission, he went gold panning and met several members of

a Christian denomination religion and had a girlfriend among them. His girlfriend encouraged him

to be evangelized and after listening to a minister, decided to convert. He remembered feeling his

hatred for the mayor and his attraction to his girlfriend go away after he was converted, so he then

left the NPA and also broke up with all his girlfriends. He also stopped smoking and drinking

alcohol but continued his activities in his fraternity until his minister forbade him to do so.

He decided to go to ministerial college, but knew that he would need a high school diploma

to qualify, so he went back to school and enrolled in his 4th year, working for his Spanish teacher

as a houseboy to pay for his tuition. When he took the National College Entrance Examination and

believed that he passed, he stopped going to school thinking that it was enough to graduate, and

instead went to work with his father drilling wells in different barangays to save up for his ministerial

studies. At the end of the school year, knowing he passed the NCEE earlier in the year, he

believed that he deserved to graduate but found that he was not on the list of graduates. He

believed that all his classmates became sad at this news, so they rallied in front of the school

administration and threatened that they will not attend the graduation if Lucas did not graduate with

them, and entreated the help of his Spanish teacher who vouched for him and paid his final tuition

so he was finally able to graduate from high school.

He dreamt of becoming a minister and worked his way to finish his studies. As he was

studying, he was sent to different provinces to do ministerial work. He had numerous girlfriends in
almost every locale he was assigned to even though as students, they were not allowed to have

such relationships, claiming that there were many girls who found him attractive and he believed

that, Maraming mga kababaihang nagpaparamdam sa akin and that he could not help but

respond to them. His first girlfriend as a ministerial student was Lorna, the daughter of the

caretaker of a church he was assigned to. He found her attractive because she was young looking

even though she was 2 years older than him, with her short stature, cute face, and mild manner.

He met her when he was 23 years old and maintained a long distance relationship with her for 3

years while having relationships with girls in other locales he was assigned to. Some of these girls

were not church members so he would often break off their relationship after a few months. When

he was finally ordained as a minister, he decided to get married to Lorna in order to distance

himself from these girls and turn over a new leaf.

He was an effective minister as he would be able to increase the size of their membership

wherever he would be assigned. However, he was also reprimanded on several occasions for

being overly friendly and familiar with young teenage girls, and was told by his supervisors to

refrain from fraternizing with them. He also had numerous conflicts with men that he worked with;

several times engaging in physical altercations with them that would get him transferred to a

different locale.

Physical and Neurologic Examination (9/25/14):

Unremarkable

Mental Status Examination (9/25/14):

Patient was seen as a middle-aged, slightly stocky man with average height, dressed in

pressed short-sleeved button-down shirt, slacks and leather shoes. His trimmed hair had some

areas of grey and was neatly parted on the side. He wore a large gold ring on his left ring finger

that he often fiddled with. He had spontaneous, normoproductive speech with normal rate and

rhythm. He had fair eye contact. He was euthymic and had appropriate affect. He denied having

any perceptual disturbances, delusions and suicidal ideations. He was preoccupied with reinstating

his position as a minister and believed that Gods mission for him is to continue this work. He had
no looseness of association or tangentiality, but was evasive and circumstantial in his answers to

questions regarding his relations with underage girls. He was oriented to 3 spheres, with good

concentration and calculation, intact memory, good fund of knowledge, good abstract thinking,

good judgment and poor insight as he believed that he did not need treatment because he does

not have an illness and only needed to be evaluated and cleared by a psychiatrist to go back to his

ministerial work.

Initial Working Impression (9/25/14):

t/c Pedophilic Disorder

t/c Narcissistic Personality Disorder

t/c Antisocial Personality Disorder

Management Plan (9/25/14):

No psychopharmacological intervention for now.

Psychoeducation.

Discuss roles of treater and evaluator. Offer both services and assign to resident-in-charge for

evaluation and resident-in-charge for treatment.

Course of Care:
Evaluation
Patient initially did not consent for treatment and only consented for evaluation. Follow-up
was given for resident-in-charge evaluator. Patient was seen by resident-in-charge evaluator for 2
sessions and referred for baseline psychological assessment as part of forensic evaluation. After
which, patient was informed that no clearance will be given at the time he was seen and that the
recommendation is for him to undergo treatment. Patient was informed that reassessment would
be done after treatment.
Patient was referred for treatment to resident-in-charge treater, to which patient finally
consented to go.
Primary Working Impression

Other specified paraphilic disorder (pedophilic disorder of less than 6 months duration)

Narcissistic Personality Disorder

Specifiers: With traits of Antagonism (manipulativeness, deceitfulness, callousness, hostility),


Negative Affectivity (depressivity) and Disinhibition (impulsivity), With moderate impairment

Persistent Depressive Disorder (Dysthymia)

Treatment
Upon seeing the patient again after being referred by evaluator, readiness for change was

assessed and noted to still be low, so initial sessions were targeted at establishing rapport and

engagement. It was only after patient was given homework to detail an account of the roles and

responsibilities of a minister an account of what he actually did while he was a minister that he was

able to see and accept that he had a problem. Planning of cognitive behavioral treatment was

done.

Psychopharmacologic intervention was done when patient was started on Fluoxetine

20mg/cap 1 cap OD for depressive symptoms and for impulsivity and aggression. Baseline

laboratory tests were requested with results still pending.