Mohamed sedkyPsychiatric specialist

BMHHFeb. 2015

Identification Data

Mr. TA a 28 years old, single, saudi gentleman, lives in buraidah, a college graduate works as a primary school teacher in algouf area, non smoker.teacher in algouf area, non smoker.

Mr. TA presented to our medical committee one month ago for psychiatric assessment.

Past History Mr. TA presented to our hospital for the first time 21 years

ago, when he was 7 years old.

The main complain was low mentality observed by his parents since he was 4 years old:parents since he was 4 years old:

أحنا صار لنا ثالث سنوات مالحظین ان الولد ما ھو طبیعي كما لو كان فیھ “”تصرفاتھ مختلفة عن باقي اخوانھ و اخواتھ, تأخر في نموه العقلي

Also he had bedwetting.

Past History

The provisional diagnosis was:

Mental retardation ( mild)

IQ test was ordered

Past History

The result of the IQ test was: 80 – 90 (average IQ)

٩٠—٨٥نتوقع أن نسبة الذكاء العام لدیھ تترواح بنسبة , من خالل المقابلة و االداء“”و یمكن ان یصنف في فئة الذكاء العادي االقل من المتوسط

He was given:

Tofranil 10 mg tab. 1x1

B complex syrup 5 ml x 2

He did not show back up till 11 years later.

Past History 11 years later, when the patient was 18 years old (secondary school), he was

brought to OPD by his parents, with the following complaints:

Past History

Differential diagnosis:

ADHD

Conduct disorder – personality disorder

Impulse control disorderImpulse control disorder

He was given tofranil 25 mg tab. 1x2 ( 2 weeks)

Past History

2 weeks later in OPD: his father reported that no improvement.

Physician noted that patient still avoiding eye contact and looks indifferent.and looks indifferent.

Past History

One week later he was presented to the medical committee (for the purpose of diagnosis) with the following conclusion:

“No ADHD disorder, and patient has antisocial traits”

قررت اللجنة عدم وجود اضطراب نقص االنتباه و فرط الحركة مع مالحظة ""بعض سمات اضطراب المسلك و ال یعطى عالج في الوقت الحالي

Past History

The school social worker called the treating psychiatrist and informed him by the following:

یتكلم كالم مالھ معنى سواء لھ مناسبة او من غیر –الولد یتكلم بدون اذن یتكلم كالم مالھ معنى سواء لھ مناسبة او من غیر –الولد یتكلم بدون اذنیمزح –المباالة عندما تكلمھ –و یقلد االصوات ویرفع صوتھ –مناسبة

یتأخر عن –یمشي بشكل غیر متزن –بثقل واحیانآ بالید مع زمالئھ .التحصیل الدراسي ال بأس–الحصص

حالتھ مزعجة و مقلقة داخل المدرسة للمدرسین و االداریین و : الخالصة .الولد فیھ مشكلھ–الطالب و صار الكل یتكلم عن حالتھ

Past History

He was reviewed by the medical committee, with the conclusion that:

“The patient has no psychotic or neurotic disorder, no “The patient has no psychotic or neurotic disorder, no personality disorder, but he shows some antisocial traits. And he in need for CBT”.

ال یوجد اضطراب ذھاني او عصابي في الوقت الحالي و لكن یوجد "و لكن ال یوجد اضطراب ) إضطراب المسلك(اضطراب سلوكي بعض سمات

الحالة ال تحتاج في الوقت الحالي الى عالج عقلي و تحتاج . شخصیة واضح"الى عالج سلوكي معرفي بواسطة االخصائي النفسي و االجتماعي

Past History

He did not show back up till 10 years later (One month ago).(One month ago).

History Of The Present Illness

One month ago he was presented to the medical committee (upon request from the court) for psychiatric assessment.assessment.

History Of The Present Illness Mr. TA and his mother was interviewed

Sample of the mother’s talk:

جنسي استدراج ,یستدرجھ حاول باكستاني عامل فیھ النھ المحكمة في قضیة لھ ھو ان المشكلة .للشرطة وسلمھم الحارس مسكھم و الجواء بعیون االنشاء تحت بمبنى ان المشكلة .للشرطة وسلمھم الحارس مسكھم و الجواء بعیون االنشاء تحت بمبنى ,یعترض ما بدون إیده في إللي یاخد صغیر طفل لو ممكن یعني تمییز قلة عنده الولد ب باسمھ البنك من قرض أخذ زمالئھ أحد .یتقالھ شي أي یصدق و سجیتھ على ھو

حسابھ رقم منھ أخذ و الباقي أخذ و ألف١٠٠ بحوالي سیارة اشترالھ و الف١٨٠.أوراقھ كل و السري

.ووافق الطبخ علینا إحنا و الذبیحة علیك إنت عزیمة نحط نبي زمالئھ قالھ مرة في و أحیانآ الولد .رزقك أقطع أبي ما أنا لكن و للتدریس تصلح ما انت قالھ المدرسة مدیر

.مسموع بصوت یفكر أحیانآ و ضحك مافیھا أشیاء على یضحك

History Of The Present Illness

Sample of the patient’s talk:

ضعیف اني مشكلتي ,بالجوف سنتین حوالي من مدرس أشتغل أنا ضعیف اني مشكلتي ,بالجوف سنتین حوالي من مدرس أشتغل أنا اظبط أعرف ما المدرسة في .إدراك و تمییز و عقل ضعف عندي ,الشخصیة

أسیطر أقدر ما الفصل من یطلعون و یدخلون ,علي یضحكون الطالب ,الصف.الطالب ادرس اعرف ما اني یقول مدیري علیھم،

و ھددني الطریق في و الجوا لعیون أوصلھ مني طلب و باكستاني عامل جاني جھ داخلین أحنا و ,یبي إیش أدري ما ,الجواء بعیون مھجورة لعمارة أخذني

صارت و أخذتنا جات و الشرطة بلغ و تسرقون تبون أنتم وقال الحارس.قضیة

Mental State Examination

Mr. TA is a 28 years old male, who looks slightly older thanstated age, he is overweight shows adequate grooming andhygiene, he showed average psychomotor activity, but withclumsy gait, During interview he was cooperative, yet,appearing anxious with limited facial expressions and wasappearing anxious with limited facial expressions and wastrying to avoid eye to eye contact. Speech is bothspontaneous and induced, of average rate, shows lowvolume and monotonous tone. No hallucinations, and nodelusions can be detected, shows slow thinking process andneeds extra time to comprehend questions. Shows restrictedanxious affect with euthymic mood. No suicidality orhomicidality can be elicited.

psychometry

IQ test result was: 79±5

With discrepancy between verbal and performance scores: With discrepancy between verbal and performance scores:

Verbal IQ Score: 87

Performance IQ Score: 72

The patient was diagnosed as a case of:

Asperger’s Syndrome

What is Asperger’s Syndrome?

What is Asperger’s Syndrome?

Asperger’s Syndrome is a neurobiologicaldisorder named for a Viennese physician,Hans Asperger, who in 1944 published apaper which described a pattern of behaviorspaper which described a pattern of behaviorsin several young boys who had normalintelligence and language development, butwho also exhibited autistic-like behaviors andmarked deficiencies in social andcommunication skills.

Demographics

gender: Estimated male-to-female ratio is approximately 4:1.

Prevelence: Prevelence:Two out of every 10,000 children have the disorder

Asperger’s Syndrome is usually diagnosed between the ages of 5 and 9.

Asperger’s Syndrome: Symptoms

•Difficulty with social interactions

•Odd Speech/Communication Style

•Difficulty with Social Imagination

•Obsessive interests•Obsessive interests

•Routine/Repetitive behaviors

•Hypersensitivity to lights, sound, smells

•Other Possible Symptoms

Difficulty with social interactions Lack basic social skills: they may stand too close, stare inappropriately or not make eye contact, have marked lack of concern over appearance, be oblivious to others’ reactions, change topics idiosyncratically. unaware of others' feelings. Difficulty empathizing or taking another person’s perspective.person’s perspective. Lacking in ability to show compassion, sympathy, and sincere happiness. naive and gullible. Behave in what may seem an inappropriate manner. Difficulty in distinguishing intimate relationships from friendships. Easily manipulated and often an easy target for bullying due to naïvety.

Difficulty with social interactions Impairments in establishing peer relationships (don’t know how to engage an appropriate way).

Sometimes appearing shy or withdrawn, but willing to speak when spoken to.spoken to.

Find people unpredictable and confusing.

Can become withdrawn and aloof.

Cannot understand the unwritten social rules that most of us take for granted.

Odd Speech/Communication Style literal in speech with difficulty understanding jokes,

sarcasm and metaphor

Needs extra time to process questions or comments.

repeat words and phrases i.e. because meaning is not repeat words and phrases i.e. because meaning is not understood

Talks in a flat affect: Speech may lack tone, pitch, and accent (like a “robot”).

Difficulty knowing when to start or end a conversation.

Odd Speech/Communication Style Few facial expressions and difficulty reading others’

body language

Lack of “common sense” and an inability to identify social cues

Intrusiveness or difficulty recognizing social boundariesIntrusiveness or difficulty recognizing social boundaries

show little eye contact

Low to no sense of humor.

Lacking in ability to greet others in a warm and friendly way.

Acting in a somewhat immature manner.

Difficulty with Social Imagination Rigid/solid thinking e.g. emphasis on learned

routines/little flexibility.

Limited intuition / little instinctive understanding.

Problem in generalizing. Problem in generalizing.

Little connection between Action and Consequence.

Difficulty with Social Imagination Disconnects - sees the detail rather than the whole

picture.

Poor problem-solving and organisational skills.

Difficulty imaging alternative outcomes to situations Difficulty imaging alternative outcomes to situations and finding it hard to predict what will happen next.

Obsessive interests Preoccupation with narrow area of interest.

Fascinated with numbers and letters.

Preoccupation with objects.

Obsessions with a single topic such as music, Obsessions with a single topic such as music, dinosaurs, or cars.

Routine/Repetitive behaviors Intense need for routine and consistency with anxiety when routines are not followed.

Stereotyped Behaviors, Activities, and Interests.

Repetitive motor movements. Repetitive motor movements.

Hypersensitivity to lights, sound, smells

Can be hypersensitive to or bothered by lights, sounds/noises, smells, strong tastes or textures

Other Possible Symptoms

Low self-esteem and self-concept: they are aware of their difference and blame themselves rather than the disability.

Often self-described “loners”.

Motor clumsiness, and physically awkward in sports.

Poor handwriting or trouble with other motor skills (i.e. riding a bike).

May show aggression.

Here … We Have Tow Questions

Is this man legally responsible for his act?

Is he fit to work as a teacher?