Thursday, December 29, 2022

antisocial narcissitic personality

source: forwarded email in 2016 by choncho s.

Understanding Duterte: What a psych report says

"Tough-talking" may be the most-used description for Davao city mayor and presidential candidate Rodrigo Duterte, but it seems that his attitude and personality are caused by a psychological condition, according to court records.

Details on how Duterte thinks were made public after a report prepared by a psychologist was entered into as evidence in the annulment proceedings initiated by his former wife, Elizabeth Zimmerman.

A report prepared by Dr. Natividad Dayan, former president of the International Council of Psychologists, concluded that Duterte was suffering from "Antisocial Narcissistic Personality Disorder,” a condition characterized by "gross indifference, insensitivity and self-centeredness," "grandiose sense of self-entitlement and manipulative behaviors" and "pervasive tendency to demean, humiliate others and violate their rights and feelings."

Zimmerman filed a petition for declaration of nullity of marriage in 1998 before the Regional Trial Court of Pasig City, alleging Duterte’s psychological incapacity.

Zimmerman, who was married to Duterte since 1973, had been residing in Pasay City at that time after their marriage turned sour 10 years prior.

'MISERABLE AND UNHAPPY'

Duterte and Zimmerman separated in July 1998. However, their marriage turned for the worse 10 years prior and they started sleeping on separate beds as a result.

"Miserable and unhappy," that was how Zimmerman described her marriage with Duterte when she took the stand, under oath and in open court.

As narrated in a decision penned by Judge Pablo M. Roxas, which granted Zimmerman's petition for nullity of marriage, Zimmerman said that her marriage with the presidential aspirant was marred with the latter’s womanizing and volatile temper.

According to official court documents, Zimmerman testified that sometime after the birth of their second child, Sara, in 1978, a woman, who introduced herself as Duterte's mistress, confronted her to inform her of her husband's illicit liaisons.

During a confrontation with Duterte, the latter acknowledged the affair and said that it was only a scheme to get back at him since his affair with said woman had gone sour.

Zimmerman testified that Duterte's womanizing continued as he had several affairs with other women while he was a prosecutor. According to Zimmerman, Duterte's womanizing worsened when he became an OIC-vice mayor of Davao City, with the politician flaunting his other women and introducing them to his friends as "Mrs. Duterte."

When confronted again about his womanizing, Duterte told Zimmerman, based on court records, “Leave me alone. I know what I am doing."

PERSONALITY DISORDER

Dayan said in her psychological report that Zimmerman suffered a “Partner Relational Problem” caused by "severe stress during her marriage to Rodrigo," and that she will continue to suffer if she remained married to her husband.

The psychological assessment concluded that Duterte was "psychologically incapacitated to handle essential marital obligations." Moreover, Duterte's antisocial narcissistic personality disorder was found to have existed prior to his marriage to Zimmerman.

A clinical examination conducted on Duterte confirmed that he was suffering from “Antisocial Narcissistic Personality Disorder.”

Among the features of said personality disorder are "inability for loyalty and commitment, gross indifference to others' needs and feelings, heightened by lack of capacity for remorse and guilt."

For years, Duterte had been criticized for his alleged involvement in extrajudicial killings in Davao City–and his apparent lack of remorse for it.

In more than one instance, Duterte admitted, perhaps in jest, to killing scores of individuals allegedly involved in criminal activities before they received their day in court.

The mayor previously admitted his links to the Davao Death Squad, which is allegedly responsible for summary executions of criminals in the city. He also warned he will kill up to 100,000 criminals if he is elected president.

In a television interview, Duterte was unapologetic about his actions and even dared the group to file a case against him in court.

"Ako, ako daw death squad? True, that's true," Duterte said on air.

He also said that instead of 1,000 dead criminals, the number might rise to 50,000 dead if he is elected president.

"Pag naging presidente ako, magtago na kayo. Yung 1,000 na ‘yan it would reach 50,000. I will kill all you [expletive] breaking the life of the Filipino miserable. Papatayin ko talaga kayo."

 I do not want to commit a crime but if by chance, God will place me there, magbantay kayo. Yung 1,000, magiging 100,000. Dyan mo makita tataba yung isda sa Manila Bay. Dyan ko kayo itapon," Duterte said.

'IMMEDIATE GRATIFICATION AND POOR JUDGMENT'

Results of Dayan's examination of Duterte showed that the mayor is likely to be "a highly impulsive individual who has difficulty controlling his urges and emotions. He is unable to reflect on the consequences of his actions."

"Immediate gratification of his [Duterte's] needs and desires is always expected; any delay can upset him a great deal," the assessment said.

The psychological assessment also found Duterte capable of destructive behavior and has poor capacity for objective judgment.

"Such lack of self-discipline often leads him to engage in unhealthy or destructive behaviors. However, he is not apt to see his behaviors as such, and instead sees these as merely exciting and challenging," the assessment found.

“As it is, he has poor capacity for objective judgment. He fails to see things in the light of facts, or at least from the point of view of most people. He interprets his actions solely from his own viewpoint, which is blemished by his personal needs, biases and prejudices,” it continued.

Duterte also tends to rationalize and justify his wrongdoings, according to the psychological assessment.

“For all his wrongdoings, he tends to rationalize and feel justified. Hence, he seldom feels a sense of guilt or remorse.”

Tuesday, December 27, 2022

Schizophrenia may be due to an overactive immune system (2015 study)

 https://www.popsci.com/an-overactive-immune-system-might-cause-schizophrenia/?dom=tw&src=SOC

>Conclusion: "the authors found that people with schizophrenia (& those at highest risk for the disease to set it) may have OVERACTIVE IMMUNE SYSTEMS working in their brains."

>n = 56 healthy vs Schiz (51 million worldwide) & Hi risk

>method: MICROGLIA cells (protects brain & CNS from pathogens that attack it) injected with radioactive biomarkers that would stick to the cells and show up in scans

>result: those with schiz & hi-risk had MORE microglia cells activity in the brain



>why? Ho: since microglia cells also WEED OUT unnecessary brain connections, the overactive microglia might be TOO OVERZEALOUS, destroying connections that the brains need so that it no longer functions properly

>current knowledge: schiz onset is 16-30 y/o -- the brain just finished its 2nd big synaptic pruning during adolescence

                             : previous studies of schiz pxs indicate that IMMUNE SYSTEM DYSFUNCTION might be written into their genetic codes

>suggested possible treatment: ANTI-INFLAMMATORY agents to SUPPRESS microglial activity  

Tuesday, December 6, 2022

DSM history of Personality Disorders' inclusion

 https://en.wikipedia.org/wiki/Personality_disorder




Thursday, September 1, 2022

self-injury definition

 https://screening.mhanational.org/screening-tools/self-injury-survey/?ref

In this survey, we want to learn more about times when you’ve hurt yourself on purpose without wanting to die. When we say self-injury, we mean doing something that causes immediate pain or physical injury.

  • Self-injury includes things like cutting, burning, or scratching your skin*.
  • Self-injury does not include things that don’t cause immediate pain, like eating too much or too little, using drugs or alcohol, or over-exercising.
  • Self-injury also does not include things that cause immediate pain but are socially acceptable, like getting piercings and tattoos.
======================================================================
*i was struck by "SCRATCHING YOUR SKIN" :-) well, dermatitis is stress-related, but not technically speaking, self-harm but could it be called "micro self-harm"? :-)
oh, I've had service users who use sharp objects to scratch their skin as though writing on it! i think this is what is intended here...

Tuesday, August 30, 2022

t/c anorexia nervosa (my first case)

 30 aug 2022

18M HPI: 10 mos PTC started self-harming (4x) due to perceived inability to live up to parental expectations. thoughts prior to self-harm "I am fat" which is contrary to reality (saw him on video cam), leading to lowered appetite.

i thought of referring him to psychiatry but I found out it was one of our psychiatrists who referred him for psychotherapy, saying that his case is not psychiatric.

i was considering the possibility of body dysmorphic disorder (under obsessive-compulsive and related disorders), but criterion D rules out "concerns with body fat or weight". 

what i forgot to ask was criterion A. PHYSICAL weight loss* defined for adults as "less than minimally normal". B. is PSYCHOLOGICAL -- "intense fear of gaining weight or becoming fat".

to code:

F50.01 restrictive type -- c/o diet, fast &/or excessive exercise

F50.02 -- c/o bing eating or purging

*severity is c/o BMI

Thursday, July 21, 2022

2 reasons for self-harm

07/20/2022 22F F33,2. F41.0, F43.10

she used to slash her wrist to overcome the psychological pain with the physical pain

later, she would do it just to feel something because of emotional & physical numbness

bx: OFW father in Saudi separated from mom when SU was 9 y/o; then, in senior high, it was mom's turn to be an OFW in Oman

Tuesday, June 28, 2022

visualization of fear by 14M F41.0 Panic Disorder

he was a service user of ours 4 years ago due to MDD & PTSD diagnosed by doc cheng triggered by "bullying" acts by a teacher. the case reached the division & regional offices of DepEd & the court but they lost there, for one reason or another.

this time, my impression is F41.0.


gun & knife = he fears them

fears of a teenaged girl with panic disorder

2022 June 28 

15F F41.0 Panic Disorder

Fears: 1. being rushed to the hospital due to panic attacks c/o inability to stop negative overthinking 2. parents with sickness (father with diabetes & mom with ongoing colon biopsy -- used to faint; fear of their death) 3. death c/o grandma died just this june.

excerpt: "Palagi po ako nag-iisp ng mga NEGATIBO sa utalk ko at minsan po di ko na kayang LABANAN. Gusto ko na lang po MAWALAN NG UTAK para hindi na po ako mag-isip." (lack of control over anxious thoughts -- symptom # 2 of Generalized Anxiety Disorder)


Friday, June 24, 2022

T/C borderline personality disorder / traits

06/23/2022 

F36S RN rated unfit for work abroad, manly in hairstyle & attire, attempted suicide when application for work in Singapore was rejected; in SSCT, admitted regretting entering into a relationship (not specified)

F17S banged head on wall when elder brother found out about her secret boyfriend

remark: symptom # 6. "Affective instability due to a marked reactivity of mood (e.g. intense episodic dysphoria, irritability, or anxiety usually lasting a FEW HOURS & only rarely more than a few days)."

panic disorder without childhood or adolescent traces

 06/24/2022 37FS RN F41.0

HPI: attacks (1) 2021 march -- on duty, (2) nov -- watching Netflix, (3) 2022 april, (4) may; (-) x-ray, ECG & blood sugar

in childhood: "malakas akong tao, di ako sanay sa ganito."

remark: possible denial, suppression, repression, modeling by adults; but with underlying predisposition (thought about the yin-yang principle)

anxiety & depression triggered by death of grandmother

 06/24/2022 F33S 4/4 F33.2, F41.0

HPI: had third eye since childhood; onset 2009 maternal grandma who took care of her died; same year diagnosed with depression & anxiety; continued psychiatric consultation moving from one hospital to another due to transfer of doctor & financial considerations; 2021 latest of many suicidal attempts by slashing wrist; once overdosed on rivotril 10 tabs

FmHx: (+) cousin (psych grad)

self-identified origin of current problem: financial difficulties c/o continued profession of mom as real estate broker but due to pandemic, clients had difficulty paying


Tuesday, May 31, 2022

siblings with autism, intellectual impairment, & ADHD

 31 may 2022

both males one aged 6 years & 9 months & the other, 7 years & 9 months.

father said mother drank alcohol when pregnant. they were on and off & now separated. father with another wife.

the younger has MILD while the older has MODERATE intellectual developmental disorder

NB: this should serve as a warning to pregnant mothers 

>"Alcohol in the mother’s blood passes to the baby through the umbilical cord. Alcohol use during pregnancy can cause miscarriage, stillbirth, and a range of lifelong physical, behavioral, and intellectual disabilities. These disabilities are known as fetal alcohol spectrum disorders (FASDs)." https://www.cdc.gov/ncbddd/fasd/alcohol-use.htm

>"There is no known safe amount of alcohol use during pregnancy or while trying to get pregnant. There is also no safe time for alcohol use during pregnancy. All types of alcohol are equally harmful, including all wines and beer."

>"Alcohol use in the first three months of pregnancy can cause the baby to have abnormal facial features. Growth and central nervous system problems (e.g., low birthweight, behavioral problems) can occur from alcohol use anytime during pregnancy. The baby’s brain is developing throughout pregnancy and can be affected by exposure to alcohol at any time."

Friday, May 27, 2022

blooshot eyes & marijuana (cannabis)

an  ER px was referred to us today when I was the only left in the MHSC bldg. the uncle said it's due to drugs. the father said he was just studying modules at home & he ended up "catanonic" & "mute" (he's normally quiet according to them).

what caught my attention, aside from an unusually clingy behavior was the bold red blood around his eyes. our lady guard also thought it was due to illegal drug use.

& so, I googled: 

ttps://americanaddictioncenters.org/health-complications-addiction/signs-drug-use-eyes

"... Bloodshot eyes are a common symptom of INTOXICATION from several drugs, especially alcohol, cocaine, & MARIJUANA: these occur because blood vessels in the eyes EXPAND.

"... PINPOINT PUPILS are a symptom of OPIOID intoxication & overdoes."

>MARIJUANA: Bloodshot eyes are one of the most common side effects of marijuana intoxication.

https://cannabis.net/blog/smoke/why-getting-stoned-gives-you-red-eyes-and-how-to-deal-with-it

"...Consuming THC (TetraHydroCannabidiol) lowers BP, which then results in DILATION of the capillaries & blood vessels. When the ocular capillaries dilate, BLOOD FLOW to the eyes are increased & intraocular pressure is then reduced. 

The increased blood flow results in red eyes while the PRESSURE DECREASE benefit patients who are suffering from GLAUCOMA.

> strains with LOW THC content --> MILD red eyes

> strains with HIGH THC content --> BLOODSHOT eyes


Thursday, May 19, 2022

prolonged grief disorder: case # 01

19 may 2022

35F teacher who on 2020 may 30 lost her newborn child. tearful when alone & the memory comes back, like posttraumatic stress. 

during psychotherapy, I asked her to dialogue with her baby through the empty chair technique & she did so tearfully, leading to some degree of closure. 

Tuesday, May 10, 2022

Nonsuicidal Self-Injury Disorder case # 01

ICD-10 Code R45.8 Other Signs & Symptoms involving Emotional States

again, for the 2nd day, got a "first". 

"nonsuicidal self-injury disorder" is now a "condition under further study" in DSM-5-TR (2022).

11 May 2022

walk-in. 36M. chief complaint: insomnia & self-injury marks on arms. 

HPI (history of present illness): ~ 9 years PTC (prior to consult) wife left for Iloilo together with their 2 kids aged 7 & 5 (bringing them there for the 1st time) & never returned. mother of SU (service user) told him she heard she already married. SU used to work in a candy factory in caloocan, then a messenger in a bank in CSJDM but lost his job due to alleged in-fighting among colleagues.

1 mo PTC SU started to cut his arm with pictures like television & fish in the evening. his daily routine includes going to the river to take a bath around lunch time & then spends the whole day watching tv or the mobile phone.

psychotherapy yielded insignificant gains due to emotional (& physical) numbness. he just went through the motions & needed to be prodded. techniques intended to elicit emotional release were largely ineffective. referred to psychiatry.

 

on permanency of autism

 10 may 2022 

i assessed this 2-year-old female service user (SU) in 2019 due to delayed speech (age 3-4 years old started to talk) without a standardized intelligence test but with a vineland social maturity scale & the childhood autism scale & SDM-5 screening tool with the diagnostic impressions of F84.0 autism spectrum disorder (ASD) with intellectual & language impairments, T/C F70 mild intellectual developmental disorder & F90.2 ADHD, combined presentation.

today, 2 years & 9 months after, at age 5 years & 8 months, we assessed her again with the help of our practicum students. i had wanted the stanford-binet to be given, but since it's not easy, I did not insist. instead, I asked that the raven's (abstract reasoning) be given since it has norms starting at age 5.3 & she got an estimated IQ of 112 (high average) & with an estimated mental age of 6 years & 4 months. 

I was in a dilemma as to whether to still give the diagnostic impression of  ASD since the full range of required symptoms are no longer present. to the credit of the parents (the SU is an ONLY CHILD!) , they completed the 12-session package with our visiting SPED interventionist & elsewhere. so, the DEVELOPMENTAL PROGRESS was phenomenal (this is the principle of EARLY INTERVENTION), plus the fact that her level of dysfunctionality is not severe (most probably mild only -- I validated this by asking the parents for comparison with diagnosed cousins with ASD as well).

since, I could not let the parents wait for additional hours (needing time to research further), i ended up limiting my diagnostic impression to T/C (To Consider) F80.0 speech sound disorder because that was the outstanding area needing remediation in the social maturity scale.

then,  I read this from DSM-5-TR (2022) on ASD, p.62 (in reference to criterion C. "symptoms must be present in the early developmental period...." which reads "Diagnostic criteria may be met when restricted, repetitive patterns of behavior, interests, or activities were CLEARLY PRESENT during childhood or at some time in the past, EVEN IF SYMPTOMS ARE NO LONGER PRESENT." (this is a verbatim repetition of DSM-5, 2013, p. 54).

moreover, DSM-5-TR adds this interesting admission of limitation: "However, the symptoms of ASD occur as DIMENSION WITHOUT UNIVERSALLY ACCEPTED CUTOFF SCORES for what would constitute a disorder. Thus, the diagnosis remains a CLINICAL one, taking all available information into account, & is NOT SOLELY dictated by the score on a particular questionnaire or observation measure" (p. 62).



Monday, May 9, 2022

panic disorder triggered by multiple marital, financial, & family-of-origin problems

10 may 2022

36F



female orgasmic disorder F52.31

06 may 2022

this is my first case of such kind. 30F with PDD (persistent depressive disorder F34.1) & panic d/o (F41.0) with history of rape in childhood & adolescence by visiting cousins from the province whenever there are no people at home.


Tuesday, May 3, 2022

family medicine rotator learning content

Re: DJNRHS Family Medicine Psychiatry RESIDENT Rotation LEARNING CONTENT

 

A.   PRIMARY CASES = The FamMed Res shall carry out all phases of Dx & Tx WITHOUT consultation in 90% of cases. The Tx will consist of SUPPORTIVE THERAPY.

1.    Stress Reaction

a.    Grief (mourning)

b.    Death, separation, etc. (with depressive & anxiety features)

2.    SITUATIONAL REACTIONS

3.    Psychosomatic Illnesses – MILD Syndrome

a.    Peptic ulcer

b.    Colitis, anorexia

c.    Asthma (with minimal psychological dysfunction)

d.    Rheumatoid arthritis

e.    Hypertension

f.     Dermatoses

g.    Migraine

 

B.    SECONDARY CASES = the FamMed Res shall maintain PRIMARY responsibility to the case but usually needs consultation at one point. Therapy mainly SUPPORTIVE with some INSIGHT-DIRECTED therapy.

1.    SITUATIONAL REACTION

2.    Psychosomatic Illnesses – SEVERE Syndrome (with greater dysfunction of the px)

3.    TRANSIENT Situational Disturbance

a.    Adjustment Reaction of Adolescence

b.    Adjustment Reaction of Late Life

4.    Chronic Psychotic, per discretion of Psychiatry Res Coord (by mutual agreement of PRC & FMR)

 

C.   TERTIARY CASES = the FamMed Res shall recognize those cases but does NOT maintain primary responsibility & refers px for both Dx & Tx.

1.    Psychoses not attributed to physical conditions

a.    Schizophrenia

b.    Affective Disorders (Affective psychosis) – involutional, manic-depressive

c.    Paranoid States

d.    Other Psychoses

2.    Neuroses

a.    Anxiety Neurosis

b.    Hysterical Neurosis

c.    Obsessive-Compulsive Neurosis

d.    Depressive Neurosis

e.    Hypochondriasis

f.     Depersonalization Neurosis

3.    Borderline syndrome

4.    Personality disorders

a.    Paranoid

b.    Cyclothymic

c.    Schizoid

d.    Explosive

e.    Obsessive-compulsive

f.     Hysterical

g.    Passive-aggressive

h.    Inadequate personality

5.    Sexual Deviation

a.    Homosexuality

b.    Fetishism

c.    Pedophilism

d.    Transvestism

e.    Exhibitionism

f.     Voyeurism

g.    Masochism

6.    Alcoholism – Drug Dependence

7.    The Psychosomatic Illnesses (psychological factors play a critical role in the illness) – duodenal ulcer, lleo-colitis, bronchial dysfunction, genital dysfunction, organic neurosis, etc.

8.    Behaviour Disorders of Childhood and Adolescence

9.    Speech Symptoms: Speech Disturbance, Disorders of Sleep, Enuresis, Coprolalia, etc.

Monday, April 11, 2022

 12 Apr 2022

My 1st gambling d/o SU. 33M. e-sabong to the point that he has accumulated debts, reverting to the cycle of addiction.



F63.0 Gambling Disorder (Filipino) 2022 April 12

Gambling Disorder [F63.0]

Pangalan ____________________________ Edad ___ Petsa ______________

Nitong mga nakaraang 12 buwan, gaano mo kadalas naranasan ang mga sumusunod [≥4]:

0 = Hindi, 1 = Madalas, 2 = Napakadalas

___ 1. Kailangang sumugal ng parami nang parami ang tayang pera para marting ang ninanais na kasabikan (kagalakan, kasiglahan).

___ 2. Di mapakali o iritable kapag sinusubukang putulin o itigil ang pagsusugal.

___ 3. Nasubukan nang i-kontrol, bawasan, o itigil ang pagsusugal nang paulit-ulit ngunit hindi matagumpay.

___ 4. Abala ang isip sa pagsusugal (halimbawa: bumabalik-balik sa isipan ang mga nakaraang karanasan ng pagsusugal, pinaplano ang mga susunod na pagsusugal, pag-iisip ng mga paraan para makakuha ng pera para isugal).

___ 5. Sumusugal kapag hindi maganda ang pakiramdam (halimbawa: nawawalan ng pag-asa, guilty, nagaalala, ninenerbiyos, malungkot).

___ 6. Pagkatapos matalo ang perang sinugal, bumabalik uli sa ibang araw para makabawi o habulin ang pagkatalo.

___ 7. Nagsisinungaling para pagtakpan ang pakalulong sa sugal.

___ 8. Nailagay sa alanganin o mawalan ng mahalgang relasyon, trabaho, o pagkakataon sa pagaaral o sa trabaho dahil sa sugal.

___ 9. Umaasa sa iba na makakuha ng pera para matugunan ang desperadong mga sitwasyong pinansyal dulot ng sugal.

=========================================================

NB: Not better explained by a MANIC episode.

Specify if: (a) Episodic = SUBSIDING symptoms for at least several MONTHS

               (b) Persistent = CONTINUOUS symptoms for several YEARS

Specify if: (1) In EARLY remission = 3-11 months NO symptoms

               (2) In SUSTAINED remission = ≥ 12 months NO symptoms

Specify Severity: Mi = 4-5, Mo = 6-7, Se = 8-9 Sx

 

Friday, April 8, 2022

2022 DSM-5-TR: Prolonged Grief Disorder

 Just out: new disorder -- Prolonged Grief Disorder & under section 2: other conditions that may be a focus of clinical attention: Non-suicidal Self-Injury

Wednesday, April 6, 2022

does autism improve with age?

 "Autism doesn’t get better or worse with age, nor can you grow out of autism. Autism isn’t like a pair of shoes which you have to break in for maximum comfort and, regardless of what you’ve heard, the idea that one day you can wake up no longer autistic, never is, never was and never will be true."

https://autisticandunapologetic.com/2020/04/26/autism-ageing-does-autism-get-better-or-worse-with-age/

Saturday, March 26, 2022

down syndrome with autism et al.

 


27 March 2022 laetare sunday (4th sunday of lent)

jeff 9M, my newfound friend i saw with mom on the street side outside the church. stricken by conscience, I went back & gave 100 pesos to mom which jeff immediately threw away. i decided to invite him to come with me which he readily did & we all ate breakfast at the nearby eatery I usually go to. then, I decided to invite both to come with me to the hospital since there are no out-patients today. we passed by my favorite fruit shake stand & I ordered 2 small glasses & 2 banana cakes from the store nearby. while waiting jeff was banging the tricycle side which made the driver impatient. 
upon reaching the building where I stay, I asked mom to give him a bath. i gave him my kamisa tsino as new clothes. then he started to manifest his stereotypic behavior, unusually so, by pumping the throw pillow in my room. then, he "played" with the toys by repeatedly pouring them out & putting them back in. he was curious about the rocking chair (his first time to see one, it seems) & wanted to turn in around and upside down. however, when put on my lap, he would struggle to free himself (typical of those with autism but uncharacteristic of down syndrome, i.e., not wanting to be touched; however, occasionally, he would spontaneously kiss his mom on the cheeks). 
when in attempted to restrain him, he would get back by throwing my toys & was successfully in destroying one of the plastic containers by constant banging on the floor. 
on the street, I gave mom my name & title & hospital name & asked her to bring jeff to me for certificate of disability. however, while in my room, I thought, what the heck, why do I need to ask mom to still bring him back since he's already here! & so, I conducted a quick assessment of what he's capable of drawing. he just threw away the pencil given to him despite my instruction to imitate what I wrote. i was able to write a report after conducting the needed social maturity scale interview. i was also able to get this photo of his above for the PWD ID required. i had to do EVERYTHING since I don't want to add any further burden to the mother who just lives by selling salt to stores for 10 pesos per pack! she said she bore jeff at age 40, with no family history of developmental disorders. 
she said her husband is ill, with cardiovascular problem I think. however, with the small income he earns, he gives it to his own mother instead of them & just gives them food, no money. she tells it like it is -- no rancour or hurt feelings, it seems.

lessons:
1. NO TSISMIS. jeff gets upset when people talk about him. i think he knows he is abnormal & talking about him OBJECTIFIES him! (thank you, Lord, for this great LESSON from one of your special children).
2. MOM'S PATIENCE. grabe! i thought the mom was too simple-minded & was somewhat looking for signs of neglect of the child. well, she has not much choice but to bring her son with her on the street to sell given the unruly, "uncontrollable" hyperactivity of jeff. nevertheless, mom constantly picked up the toys & put them back. 

DX: Autism Spectrum Disorder
       T/C Severe Intellectual Disability
        Speech Sound Disorder
        ADHD Combined Type
(this is what we call "kumpletos rekados"!)