New Day Recovery Center,

Inc.

The Case of

ben DE LOS SANTOS rizal

 PURPOSE

This undertaking is meant to

screen and identify evidences
of underlying physical, mental
and psychological dysfunctions
in the client as basis for full
clinical diagnosis, case
management & therapeutic
intervention by the
multidisciplinary team of NDRC.
 OBJECTIVES
This case conference aims to:
Discuss pertinent information about the client;
Discuss the reason for admission, medical and
developmental history, and psychological assessment of
the client;
Elaborate the diagnosis of the client using the DSM-IV-TR
format and;
Discuss the possible therapeutic treatment and
approaches for and on the client.
 Identifying Information
Name: rizal, ben De los Santos
Age/Sex: 45/Male
Birth Date: December 31, 1969
Birth Place:
Occupation: Construction Manager/Municipal Councilor
Civil Status: Married
Religion: Roman Catholic
Address:
Date of Admission:
 FAMILY COMPOSITION
STATUS/
NAME RELATION AGE
OCCUPATION

Father 72 Municipal Mayor

Mother 67 Housewife

Sister 47 Businesswoman

Brother 44 ABC
 FAMILY COMPOSITION
STATUS/
NAME RELATION AGE
OCCUPATION

Wife 44

Son 23

Son 21

Student
Daughter 20
Premorbid History

Patient was a good provider to his family, known to be

workaholic, strict father (military type) in terms of disciplining
his children. He was an average performer in school from
elementary until high school. He is close to his mom when he
was young.

He wasnt able to finish his course because he focused

more on his job at his uncles prawn farm business. The said
business didnt prosper so his uncle ventured into road
construction business and made him manager. He became
successful in managing the said firm, claiming that its success
were due to all his efforts and hard work.
Prenatal/Infancy
Patient was delivered via NSVD; breastfed for six months and
bottle fed thereafter.

Early and Middle Childhood

He studied at Chinese school and was an average student
during his pre school years. He stayed with his grandparents because
his parents were so busy with their business trips.

Personal Social History

Middle Childhood Adolescence
At age 13 he started drinking alcoholic beverages which
affected his focus on his studies. At this time he impregnate his
girlfriend but he wasnt able to take the responsibilities of being a
father because he was still young and no source of income. He
was able to finish high school though.

Adulthood:
Pt. studied Business Administration during college. His
hobbies would include: taking care of his pet snake and bonsai
plants. He plays guitar, basketball and golf. Also, he does firing
session with friends.
He used to help in managing and supervising their family
business (JCL Trucking). Every Sunday, he spends time with his
family; they usually went out for family outing, attend church
mass, watch movies, go malling and eat lunch/dinner together.
 FAMILY DYNAMICS

The father is the decision maker in the family and whenever

the Pt. asks for money, he would provide and would never ask why.
His father is hardworking, humble, patient and very loving.
The mother is also hardworking but caring and
understanding.
The Pt. is most close to his youngest brother, Michael
because they share the same interests. They usually have out-of-
town bonding.
The Pt. is least closed to his eldest sister, Guani because
they often have conflicts and different interests. Yet, he seeks his
sisters help everytime he needs financial assistance because his
sister has more resources than his brother.

The family usually have dinner together and goes to church

as much as they can.
 History of Present Illness

19 - 40years old At age 19 patient started using illegal drugs such as

methamphetamine hydrochloride also known as shabu. He stopped
using drugs at age 21 until 40 years old. At 23 he got his wife pregnant.
He became verbally and physically abusive as verbalized by the patients
wife. He also became abusive to his children. Though he remained sober
from drugs at this age till patient turned 40.

41 years old - He used shabu again but this time almost on a daily
basis by himself. His wife noticed his hyper-activeness. He became
defiant and had inadequate sleep and loss of appetite. Patient
claimed that politics and work related stress were the reasons of his
relapse.
 History of Present Illness
41 years old - The patient became abusive again physically,
emotionally and psychologically, not spared from these abuses are
their children all of whom are too afraid to expose their sufferings
which prompted her wife to file a petition in RTC Cebu City. This was
settled but the conditions were not complied by the patient.

42 years old - The wife went to work abroad when she came back
home in October 2014 the family and relatives intervened for both
parties for the sake of their children. Patient promised to change and
mend his ways, the wife gave him another chance albeit apprehension
in order to start anew. The patient was amiable at first but turned
unsettled and alarming again after a while. His behavior was extreme
ranging from meek to agitated.
 History of Present Illness

Things turned out from bad to worst in the morning of December 2014
when patient went berserk forcing her wife to open her facebook
account. He locked his wife inside the masters bedroom and pulled out
a .45 caliber pistol and pointed the gun at her temple and uttered,
KASAYOD KA UNSAY PLANO NAKO KARON, PATYON TA KA BAG-O KO
MAG HIKOG ( DO YOU KNOW WHAT MY PLAN IS, I WILL KILL YOU FIRST
BEFORE I WILL COMMIT SUICIDE SUICIDE) and then hit her head with
his fist causing her to fall on the bed. At this point the patient thereafter
went on top of her and covered her mouth and nose with his hands
almost causing her to faint, while shouting PATYON TA KA
( I WILL KILL YOU). This happened three times. The wife thought it was
her end but patient stopped then pointed the gun at his wifes right
thigh demanding her to admit that she is having a relationship. Patient
continued his rants until in the afternoon. He then left the house but
told his wife not to go anywhere or someone will die.
 History of Present Illness
The wife was forced to leave with her daughter for fear of her life and
have to stay with her close relatives. Her two boys were forced to stay
with their father out of fear. She has to summon all of her strength to
endure the pain once again and file a new case for her protection and
her children. The wife was granted a Temporary Protection Order.

45 years old - January 03, 2015 Patient decided to voluntarily admit

himself in this facility, he was accompanied by his family.
 FAMILY HISTORY

Medical: DM, Asthma

Fathers Side
Psychiatric: None

Medical: HPN
Mothers Side
Psychiatric: Depression

(+) DM (type 2)
(+)HPN
Upon Admission (January 03, 2015)
Patient is wearing purple shirt and orange short pants. He was well
groomed.
Posture and gait normal; movement normal. Pt. looked worried but was
cooperative during the interview. With good eye contact.
Talk was spontaneous and relevant with fair accessibility.
Mood was said to be euthymic with appropriate affect.
Depersonalization, derealization, suicidal and homicidal potentials were
noted.
No noted disturbances in thought content.
Sleep and appetite were said to be normal, with increase in weight.
Orientation to time, place, person and situation he is in is unimpaired.
Memory intact. General knowledge, abstract thinking, judgment and
reasoning unimpaired.
Disturbances in insight noted.
Summary: Functional, Non-psychotic.
Mental Status Exam
 Before
After
 PSYCHOLOGICAL
TEST EVALUATION
 Purpose of Evaluation:

To determine the intellectual capacity, personality

dynamics and psychological adjustment of the
Subject as part of a comprehensive case study and
clinical diagnosis. Results shall further assist in
providing psychotherapeutic interventions.
Psychological Tests Administered:

Ravens Standard Progressive Matrices

Projective Drawings: Draw-a-Person (DAP)
House-Tree Person (HTP)
Minnesota Multiphasic Personality Inventory -2 (MMPI-2)
Millon Clinical Multiaxial Inventory-III
(MCMI-III)
Maryland Addictions Questionnaire (MAQ)
SACHS Sentence Completion Test (SSCT)

DATE ADMINISTERED:
June, 2015
 Test Results and Interpretatio
A. Intellectual Functioning

1. Ravens Standard Progressive Matrices:

Percentile Score: 50%

INTERPRETATION:

AVERAGE
1. Projective Drawings:

expansive, euphoric, or grandiose tendencies; emotional; expression of both

discharge of aggression and of concealment; tendency to be disrespectful
indicate aggressive and expansive tendencies with paranoid conditions;
hypersensitivity and distrust
strong intellectual striving; considerable fantasy activity as source of
satisfaction; possible grandiosity and egocentric attitudes based on feelings of
inadequacy
expressions of virility conflicts brimming over into some sexual deviant
behavior; indicates a need for physical power, possible aggressive, acting-out
tendencies; excessive defensiveness; concern for power and strength;
narcissistic and/or bossy tendencies
strong sexual concerns impulsivity
1. Projective Drawings:

indicate extreme tension or anxiety and conflict possibly the conflict is

causing anxiety and is disturbing the person in everyday adjustment;
fearfulness; tendency to anticipate frustration

suggests lack of confidence in social contacts or in productivity or both; indicate

a feelings of difficulty in interpersonal relationships; need for emotional
satisfaction

introversive, self-absorbed; reluctance to interact

1. Projective Drawings:

regression, and dependency; immaturity

depression;; insecurity; inhibition; introversive; withdrawal tendencies; loss of

autonomy; feelings of helplessness; discouragement; schizoid; possible suicidal
feelings

poor reality testing; psychotic features; need for flight from a frustrating
environment subjects felt need to maintain personality intactness
2. SACHS Sentence Completion Test:
Free associations on the SSCT suggest-

Family Unit

feels that he is treated like a baby in the family

expresses his longing that if only his father had a better job, they could
have been more financially stable at this time he also expresses his
sadness having a feeling that his father doesnt seem to love his
mother anymore; however, he still carries the desire deep within to be
with his father

sees his relationship with his mother as very close stating that they
always have each other and that they are always together even when
sleeping
2. SACHS Sentence Completion Test:
Free associations on the SSCT suggest-

Self-Concept
shows the tendency to run-away from problems

positive perception towards future looking forward to a brighter future and

hoping for the best in life

vague responses to some questions concerning his past.. responses such as

the worst thing he ever did was kissing her forehead he would do anything to
forget the time ang tao kong minamahal and that he felt guilty about
pagkakita ko sa kanya bago siya pinaslang

secret ambition: to become a superman

fear: heights
2. SACHS Sentence Completion Test:
Free associations on the SSCT suggest-

Interpersonal Relationship

believes that true friendship means being there always in good

and bad times; dislikes naggers he specifically stated that he
doesnt like naggers like his wife

sees himself as a diligent, honest, obedient and respectful leader

and a follower to his colleagues
2. SACHS Sentence Completion Test:
Free associations on the SSCT suggest-

Perception towards Heterosexual Relationship

perceives women as individuals who simply loves shopping

and relaxing

takes marriage seriously having mentioned that a married

life ay hindi biro
Maryland Addictions Questionnaire (MAQ)

Validity Scores
Standard
Scales Interpretation
Score
Response
39 Very Low
Inconsistency (INC)
Defensiveness (DEF) 36 Very Low
Summary Scores
Emotional Distress (EMO) 42 Low
Resistance to Treatment
37 Very Low
(RES)
Admission of
34 Very Low
Problems (ADM)
Maryland Addictions Questionnaire (MAQ)

Substance Abuse Scales

Alcoholism Severity
34 Very Low
(ALC)
Drug Abuse Severity
44 Low
(DRU)
Craving (CRA) 44 Low
Maryland Addictions Questionnaire (MAQ)

Treatment Scales
Motivation for Treatment (MOT) Very Low
 3. Minnesota Multiphasic Personality Inventory-2:

Profile Validity Scales

Measures of Inconsistent
Profile Validity
Responding Scales

Profile is Valid; but

Variable Response
characterized by some
Inconsistency (VRIN)
inconsistent responding

Profile is Valid; but

True Response
characterized by some
Inconsistency (TRIN)
non-acquiescence
 3. Minnesota Multiphasic Personality Inventory-2:

Measures of Defensiveness Scales

Lie (L) Likely invalid

Correction (K) May be invalid

 3. Minnesota Multiphasic Personality Inventory-2:

Clinical Scales Interpretation

Hypochondriasis (Hs1) Very High

Depression (D2) Very High
D1 Subjective Depression High
D2 Psychomotor Retardation Very High
D3 Physical Malfunctioning High
D 4 Mental Dullness High
3. Minnesota Multiphasic Personality Inventory-2:

Hysteria (Hy3) Very High

Hy3 Lassitude-Malaise High
Hy4 Somatic Complaints Very High
Hy5 Inhibition of Aggression Very High
Psychopathic Deviate (Pd4) Very High
Pd1 Familial Discord High
Pd2 Authority Problems High
 3. Minnesota Multiphasic Personality Inventory-2:

Paranoia (Pa6) High

Pa3 Naivete High
Psychasthenia (Pt7) High
Schizophrenia (Sc8) Very High
Sc6 Bizarre Sensory Experiences Very High
Social Introversion (Si0) Moderate
 3. Minnesota Multiphasic Personality Inventory-2:

Content Scales T-Score Level

Anxiety (ANX) Moderate
Fears (FRS) Moderate
Health Concerns (HEA) Very High
HEA1 Gastrointestinal
High
Symptoms
HEA2 Neurological
Very High
Symptoms
 3. Minnesota Multiphasic Personality Inventory-2:

Supplementary Scale
Personality Psychopathology Five
T-Score Level
Scale
Negative
Emotionality/Neuroticism Moderate
(NEGE)
Introversion/Low Positive
Emotionality (INTR)
Very High
 3. Minnesota Multiphasic Personality Inventory-2:

Broad Personality Characteristics

Very
Repression (R)
High
Ego Strength (Es) Low

Marital Distress Scale (MDS) High

Behavioral Dyscontrol
Very
Overcontrolled Hostility (O-H) High
4. Millon Clinical Multi-Axial Inventory-
III (MCMI-III)

CORRECTIONS SCALES
INTERPRETATION
Validity Index
Scale V (Invalidity) Valid

Scale W (Inconsistency) Valid

Modifying Indices
X Disclosure Valid
Y Desirability Average
Z Debasement Average
 4. Millon Clinical Multiaxial Clinical
Inventory- III (MCMI-III)

DIAGNOSTIC SCALES
SEVERITY RATING
(Personality Pattern)

Presence of Personality
1 Schizoid
Trait
Presence of Personality
2A Avoidant Trait
 4. Millon Clinical Multiaxial Clinical
Inventory- III (MCMI-III)
DIAGNOSTIC
SEVERITY RATING
SCALES

(Severe Personality Pathology)

C Borderline Presence of Personality Trait

 4. Millon Clinical Multiaxial Clinical
Inventory- III (MCMI-III)

DIAGNOSTIC
SEVERITY RATING
SCALES

Severe Clinical Syndromes

SS Thought
Presence of the Clinical Syndrome
Disorder
CC Major
Presence of the Clinical Syndrome
Depression
 FACET SCORES FOR HIGHEST PERSONALITY
SCALES BR 65 OR HIGHER
Highest Personality Scale:
Scale 2A Avoidant

tendencies to be socially anxious due to perceive

expectations of rejection
hypersensitive to rejection, both fearing and
anticipating negative evaluations may manifest a
wary detachment; quite sensitive to signs of
disapproval, depreciation, and rejection may use
fantasy as main defense; risk for developing social
phobias.
 FACET SCORES FOR HIGHEST PERSONALITY
SCALES BR 65 OR HIGHER
2nd Highest Personality Scale:
Scale C Borderline

Scale Interpretation

C.3 Uncertain Self-Image HIGH

experiences the confusion of an immature, nebulous, or
wavering sense of identity, often with underlying feelings of
emptiness.
seeks to redeem precipitate actions and changing self-
presentations with expressions of contrition and self-
punitive behavior.
 FACET SCORES FOR HIGHEST PERSONALITY
SCALES BR 65 OR HIGHER
3rd Highest Personality Scale:
Scale 1 Schizoid

Scale 6B Sadistic Interpretation

1.2 Interpersonally Unengaged HIGH

seems indifferent and remote, rarely responsive to the actions
or feelings of others.
chooses solitary activities and has minimal human interests.
neither desires nor enjoys close relationships, preferring a
peripheral role in social, school, and family settings.
 Multi-Axial Assessment

Severe Substance Use Disorder (Amphetamine type)

AXIS I Alcohol Use Disorder
Depression
AXIS II Avoidant, Borderline, Schizoid traits
Hypertension
AXIS III Hypercholesterolemia
Diabetes mellitus II
Legal Problems
Marital Issues
AXIS IV Occupational Problems
Access to Funds

GAF 60: Moderate symptoms, moderate impairment in

AXIS V
social and occupational functioning.
Readiness for Treatment
Date: June 4, 2014

Area of Raw Docile

Interpretation
Assessment Score Score
Recognition Bet. Medium and
31 40
Low

Ambivalence 7 10 Very Low

Taking Steps 30 70 Low

 The URICA is a 32-item self-report measure that includes 4
subscales measuring the stages of change: Precontemplation,
Contemplation, Action, and Maintenance. Responses are given
on a 5-point Likert scale ranging from 1 (strong disagreement) to
5 (strong agreement). The subscales can be combined
arithmetically (C + A + M PC) to yield a second-order
continuous Readiness to Change score that can be used to
assess readiness to change at entrance to treatment.

Score = 10.14 classified under

Preparation Stage
 CONTEMPLATION ACTION

PRE-CONTEMPLATION PREPARATION MAINTENANCE