The PHILIPPINE JOURNAL of

PSYCHIATRY
Official Journal of the Philippine Psychiatric Association

PSYCHIATRY AND
SPIRITUALITY:
RELATIONSHIPS AND
IMPORTANCE IN
PSYCHOTHERAPY

HAROLD G. KOENIG, MD

EXAMINING MENTAL HEALTH AND

DIVERSITY AND COLLABORATING
TOWARDS IMPROVED MENTAL
HEALTH FOR ALL

ANTHONY P. S. GUERRERO, M.D.

THE USE OF AN ILLUMINATIVE

EVALUATION APPROACH IN THE
IMPLEMENTATION ASSESSMENT
OF A
HIGHER EDUCATION INSTITUTE
COURSE OFFERED IN THE
PANDEMIC

EVANGELINE B. DELA FUENTE, MD

NEIL RYAN MARCOS MD

A QUALITATIVE STUDY ON THE
FACEBOOK EXPERIENCE OF
VOLUME 4, ISSUE 1 YOUNG
ISSN 2980-4884 ADULT UNIVERSITY STUDENTS IN
JANUARY-JUNE 2023 METRO MANILA

CHRISTI ANNAH V. HIPONA, MD

TYING IT ALL TOGETHER:

CASE OF AUTISM SPECTRUM
DISORDER WITH PARAPHILIC
ACTIVITIES

MELANIE TONGOL, MD
 PHILIPPINE PSYCHIATRIC
PHILIPPINE JOURNAL OF PSYCHIATRY
ASSOCIATION

BOARD OF OFFICERS 2023 EDITORIAL BOARD 2023

Georgina Gozo- Oliver, MD, DPBP, FPPA (Life), FPSCAP
ROBERT D. BUENAVENTURA, MD, FPPA (LIFE) Editor - in – Chief
PRESIDENT
Anthony T. Abala, MD, DSBPP
ARNOLD ANGELO M. PINEDA, MD, FPPA, FPNA Hecil Cruz, MD, DSBPP
VICE PRESIDENT Anna Josefina Vazquez-Genuino, MD, MPH, DPBP, FPPA (Life),
FPSCAP
JOAN MAE G. RIFARAEL, MD, FPPA Manuscript Editors
SECRETARY
Nikki Kristy A. Osorio-Grapilon, MD, DSBPP
Business Manager
HANNAH MARTELLA M. PAJARILLO, MD, FPPA
TREASURER
Norieta Calma- Balderrama MD, DPBP, FPPA (Life), FPSCAP
Alma Lucindo Jimenez, MD, FPPA (Life)
ANNA LIZZA Y. SALAZAR-MAÑALAC, Christi Annah V. Hipona, MD, DSBPP
MD,FPNA,FPPA,FPSCAP Sedric John V. Factor, MD
PUBLIC RELATIONS OFFICER Associate Editors

DOLORES Y. ORTEGA-LARGO, MD FPPA ANN JOY AGUADERA, MD, FPPA, FPSCAP

EVANGELINE BASCARA DELA FUENTE, MD, MHA, MHPED, FPPA
AUDITOR TOMAS D. BAUTISTA, MD, MSC, FPPA
CARMINA G. BERNARDO, MD, FPPA, FPCPSYCH
MA. RUTH BORDADO, MD, DPBP, FPPA
ROBERT GERARD O. KELEMEN, MD, FPPA MARY AGNES L. BUSUEGO, MD, MBETH, FPPA
MARY DARYL JOYCE LINDO-CALLEJA, MD, FPPA, FPSCAP
DIRECTOR OF LUZON ROBERT CAPISTRANO, MD, FPPA
CARLO PAOLO S. CASTRO, MD, DPBP
AIMEE G. CHUA, MD, DPBP
JOY R. ADOLFO- BUENO, MD, FPPA VIVIENNE CLEOFAS, MD, FPPA
DIRECTOR OF VISAYAS CORAZON ANGELA M. CUADRO, MD, FPPA
EVELYN G. GAPUZ, MD, EMBA, FPPA, FPSCAP
MARIA CYNTHIA R. LEYNES, MD, MSC, FPPA, FPSCAP
JOSE L. CORUÑA, JR., MD, FPPA MA. LOURDES CORRASLES-JOSON, MD, FPPA, FPNA
MARIFE P. MARANAN, MD
DIRECTOR OF MINDANAO MELISSA PAULITA V. MARIANO, M.D., MSC, FPPA
DINAH PALMERA P. NADERA, MD, MSC., MIMH, FPPA
ANN PRINCESS P. GRANA-NESPRAL, MD, FPPA
ANTONIO C. SISON, MD, FPPA (LIFE), FPDS MARIA LUZ S. CASIMIRO-QUERUBIN, MD, FPPA (LIFE), RANZCP (AFFILIATE)
ENCARNITA RAYA-AMPIL, MD, FPNA, FPPA
IMMEDIATE PAST PRESIDENT PIA NATALYA T. REYES-SIA, MD, FPPA
JOAN MAE PEREZ- RIFAREAL, MD, FPPA
ELEANOR RONQUILLO, MD, FPPA
HON. JUDGE ROSALINA L. PISON (RET.) GERALDINE SAYO, MD
LEGAL ADVISOR AIZAH JOYCE LEI T. TANA, MD, FPPA
SALVADOR BENJAMIN D VISTA, MD, FPPA(LIFE), FPCPSYCH, FPCAM
BOARD OF REVIEWERS

All communications should be directed to the Editor-

THE PHILIPPINE JOURNAL OF PSYCHIATRY is published twice a year in-Chief, Philippine Journal of Psychiatry, Philippine
by the Philippine Psychiatric Association. All articles published Psychiatric Association Office, Suite 1011 Medical
represent the opinions of the authors and do not reflect the official
Plaza, Ortigas Condominium, #25 San Miguel Avenue,
Ortigas, Center, Pasig City, Philippines or through
policy of the Philippine Psychiatric Association unless this is clearly email at
specified. The publisher cannot accept the correctness or accuracy of [email protected].
the advertiser’s text and/or claims or opinions expressed. The
appearance of the advertisements in this journal does not necessarily Telephone/Fax: +63(2)635-9858
constitute an approval or endorsement by the Philippine Psychiatric Cellphone: (0917) 803 1198
Association of the product or service advertised. Advertisements are
accepted through the Managing Editor and are subject to approval by
Copyright: 2023 by the Philippine Psychiatric
the Editorial Board. The contents of this publication are not to be Association, Inc.
quoted in the press or reprinted for general distribution for
advertising and promotional purposes, nor for creating new collective
works or for resale, without permission of the Editor-in-chief &
Editorial Board. Cover:
Rising from the Seige by Neil Ryan Marcos, MD with
permission from the artist

2023 · VOLUME 4 (1-2)

 PJP TABLE OF CONTENTS

SPECIAL ARTICLES PAGE

Psychiatry and Spirituality: Relationships and Importance in

Psychotherapy
1
Harold G. Koenig, M.D.

Examining Mental Health and Diversity and Collaborating towards Improved 10

Mental Health for All
Anthony P. S. Guerrero, M.D.*

The Use of an Illuminative Evaluation Approach in the Implementation 14

Assessment of a Higher Education Institute Course offered in the Pandemic
Evangeline B. dela Fuente, MD, MHA, MHPEd

ORIGINAL RESEARCH
A Qualitative Study on the Facebook Experience of Young Adult University 22
Students in Metro Manila
Christi Annah V. Hipona, MD

CASE REPORT
Tying it all Together: Case of Autism Spectrum Disorder with Paraphilic 34
Activities
Melanie Tongol, MD

ABSTRACTS

Clinical experience with Paliperidone Palmitate in a specialty hospital in the

Philippines: A short report
47
Amadeo A. Alinea, Jr., MD, FPPA*, Carl Abelardo T. Antonio, Amiel Nazer C.
Bermudez, Kim L. Cochon, Maria Fatima V. Martinez, MD, Jonathan P. Guevarra

Profile of National Center for Mental Health (NCMH) Employees‘ Dependents

on Internet Use
48
Raymond Joseph S. Valdez, MD, Gia Pauline S Castillo- Mojica, MD, Venus Serra-
Arain, MD, FPPA, MHA

INFORMATION FOR CONTRIBUTORS 49

 PJP SPECIAL ARTICLE

PSYCHIATRY AND SPIRITUALITY: RELATIONSHIPS AND

IMPORTANCE IN PSYCHOTHERAPY*

HAROLD G. KOENIG, M.D.

PROFESSOR OF PSYCHIATRY & BEHAVIORAL SCIENCES
ASSOCIATE PROFESSOR OF MEDICINE
DUKE UNIVERSITY MEDICAL CENTER, DURHAM, NORTH CAROLINA
ADJUNCT PROFESSOR, DEPT OF MEDICINE, KING ABDULAZIZ
UNIVERSITY, JEDDAH, SAUDI ARABIA
ADJUNCT PROFESSOR OF PUBLIC HEALTH, NINGXIA MEDICAL
UNIVERSITY, YINCHUAN, P.R. CHINA

ABSTRACT

This paper summarizes a lecture on psychiatry and spirituality, which examined research on
the relationship between religion, spirituality and mental health, and discussed the
importance of addressing spiritual issues in psychotherapy. In this article, religion and
spirituality are first differentiated from one another. Next, research on the relationship
between religion and mental health is examined. Third, a theoretical model is presented
explaining how religious involvement may affect mental and social health. Fourth, a review of
religious/spiritually-integrated psychotherapy is presented with a focus on
depression/anxiety, moral injury, and PTSD. Finally, further resources for more information
about the topic is provided. Because many people in the Philippines are religious, and religion
affects mental health one way or the other, it cannot be ignored by psychiatrists who practice
in this country.

KEYWORDS: religion, spirituality, depression, anxiety, suicide, substance abuse, moral injury,
PTSD, psychotherapy, spiritual history

*This paper was presented on 11-24-22 at the University of the Philippines’ Philippine General Hospital for the
psychiatry and spirituality lecture.

Corresponding author: Harold G. Koenig, M.D., Department of Psychiatry, Box 3400 Duke University Medical Center,
Durham, NC 27710.
T:19196816633. Cell: 19199493854, F:19194713624,
E-mail: [email protected]. Orchid: 0000-0003-2573-6121

1 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

INTRODUCTION (6) Leurent et al., 2013; (7) Upenieks & Ford-
Robertson, 2022).
For most of recorded history, religion and
spirituality were considered one and the same. Because of the difficulty in measuring
However, within the last 20-30 years, they have spirituality and concerns about use of
become separate but with overlapping contaminated measures, this review of the
constructs. On the one hand, religion is viewed as research focuses on the relationship between
potentially divisive and unpopular; however, religion and mental health. Religion can be
religion can be quantitatively measured and quantitatively measured, there is general
examined in relationship to other health agreement on the definition of the term (beliefs
outcomes. On the other hand, spirituality is and practices related to the transcendent), and
popular, inclusive, and common to all; however, religion is sufficiently distinct to avoid
it is now largely self-defined, making it difficult conceptual overlaps with measures of mental
to measure and quantify for use in research health. When measuring spirituality for research
studies. The traditional understanding of purposes (as some investigators may wish to do),
spirituality was that it referred to deeply measures should not be contaminated with
religious individuals, often used to describe the positive psychological states or positive
clergy or religious leaders whose lives centered character traits like those above that signify
on and revolved around their religious faith. good mental health. This will help to avoid
defining spirituality a-priori as good mental
In recent times, however, spirituality has been health (and avoid the tautological associations
conceptualized as broader than religion. Now, that would otherwise result). In clinical work,
one can be spiritual but not religious. Unclear, however, a broadly inclusive term such a
however, is exactly what “being spiritual but not spirituality is an ideal term to use and should be
religious” actually means and how to quantify it defined by patients themselves, so as to
for research purposes. As a result, researchers maximize connection, engagement, and
have begun to define and assess spirituality conversation.
using indicators of positive mental health, i.e.,
having meaning and purpose in life, being METHODOLOGY & RESULTS
peaceful, and having strong connections with This summary review is based on a systematic
others (the outcome, not the source, of review of the research contained in the second
spirituality) (1) Koenig et al., 2008; (2) Tsuang & and third editions of the Handbook of Religion
Simpson, 2008). Measures of spirituality used in and Health (8) Koenig et al., 2012; (9) Koenig et
research today reflect this trend e.g., FACIT-SP, al., 2023). Briefer reviews of the literature are
Daily Spiritual Experiences Scale, existential also available (10) Koenig et al., 2020a; (11)
well-being subscale of the Spiritual Well-Being Balboni et al., 2022).
Scale, Spiritual Transcendence Scale, etc.
Depression.
An unfortunate feature of this trend has been to
define and measure spirituality a-priori as Our 2012 systematic review identified 444
having good mental health, rather than published studies that had quantitatively
conducting scientific research to determine examined the relationship between religious
whether spirituality (uncontaminated by involvement and depressive symptoms or
indicators of mental health) is positively or depressive disorder (8) Koenig et al., 2012). Of
negatively related to mental health. The result those, 272 (61%) reported that greater religious
has been tautological, meaningless positive involvement was associated with less depression
associations between spirituality and mental and faster recovery from depression.
health (1) Koenig et al., 2008; (3) Garssen &
Visser, 2016; (4) Garssen et al., 2016). In fact, Furthermore, randomized controlled trials have
there is growing research showing that being found that religious interventions significantly
spiritual but not religious is associated with reduce depressive symptoms (12) Captari et al.,
worse mental health, increased likelihood of 2018; (13) Koenig, 2018). More recent research
depression, increased anxiety, and increased summaries of randomized controlled trials (14)
substance use disorders (5) King et al., 2013; Marques et al., 2023) and prospective cohort

2 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

studies corroborates these earlier findings. For Wu et al. in 2015 (19) found a 62% reduction in
example, in a longitudinal study of 9,862 young suicide risk among those who were more
adults (average age 23) for up to six years, religious (pooled OR=0.38, 95% CI= 0.21–0.71).
researchers at the Harvard School of Public
Health found that those attending religious Substance Use Disorders
services weekly or more at baseline were nearly Alcohol use, abuse, and dependence are less
one-third (31%) less likely to develop a common among those who are more religious,
depressive order during follow-up (RR=0.69, and the same is true for illicit drug use. The
95% CI=0.57-0.84) (15) Chen et al., 2020a). systematic review of research by Koenig et al in
2012 (8) identified a total of 278 quantitative
Suicide studies that examined the relationship between
The systematic review of Koenig et al in 2012, religious involvement and alcohol use. Of those
identified 141 studies that had examined the studies, 240 (86%) reported significantly lower
relationship between religiosity and suicide. (8) alcohol use, abuse, and dependence among those
Of those, 106 (75%) reported significantly fewer who were more religious. With regard to illicit
suicidal thoughts, attempts, and completed drug use, the systematic review identified 185
suicide among those scoring higher on measures studies, of which 155 (84%) reported significantly
of religious involvement. lower levels of use or abuse among the more
religious. Research conducted since then has
More recently, studies from the Harvard School confirmed these findings using better
of Public Health have reported that frequency of methodology (9) Koenig et al., 2023).
religious attendance consistently predicts lower
risk of death by suicide. For example, in a study For example, Sharma et al. in 2017 (20) found
of nearly 90,000 women followed from 1996 to that in a study of a nationally representative
2010, the risk of completed suicide was 84% sample of 3,151 U.S. veterans, those scoring high
lower among women who attended religious on religiosity (using a 5-item measure of
services at least weekly compared to non- religious involvement, the Duke University
attenders (HR=0.16, 95% CI=0.06-0.46) (16) Religion Index) were 34% less likely to have a
Vander Weele et al., 2016. history of alcohol use disorder (OR=0.66, 95%
CI=0.46-0.93) and were 72% less likely to have a
Likewise, deaths of despair (due to alcohol, current alcohol use disorder (OR=0.28, 95% CI =
drugs, or suicide) among 66,492 women health 0.19-0.41).
professionals followed for 16 years were almost
70% lower among frequent attendees compared Anxiety and PTSD.
to non-attenders (HR=0.32, 95% CI=0.16-0.62) The systematic review of Koenig et al in 2012 (8)
(17) Chen et al., 2020b). The findings were identified 299 quantitative studies examining the
similar for 43,141 male health professionals relationship between religiosity and anxiety. Of
followed for 26 years who were almost 50% less those, 147 (49%) reported significantly lower
likely to die from a death of despair (HR=0.51, anxiety among the more religious, while 33 (11%)
95% CI=0.37-0.70, age-adjusted) (17) Chen et al., reported a positive relationship with greater
2020b). anxiety. However, 31 of the latter 33 studies were
cross-sectional, raising the possibility that
Even a larger effect on suicide rate has been anxiety may have led to an increase in religiosity
reported in the general U.S. population, where in order to cope with the anxiety. More
an 18-year follow-up of a national random importantly, of 40 experimental studies or
sample of over 20,000 adults participating in the clinical trials, 29 (73%) reported significant
NHANES-III study found a 94% reduction in risk reductions in anxiety in response to religious or
of completed suicide among those attending spiritual interventions.
religious services at least twice/month (HR=0.06,
95% CI=0.01-0.54) (18) Kleiman & Liu, 2014). With regard to PTSD, numerous studies have
These findings were independent of gender, age, reported lower rates among individuals with
size of household, previous suicide attempt, and higher levels of religious involvement (8,9)
illicit drug use. Finally, in a meta-analysis Koenig et al., 2012; 2023). For example, when
involving nine studies with a total sample of studying the representative sample of 3,151 U.S.
2,339 suicide cases matched up to 5,252 controls, veterans described earlier,

3 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

Sharma et al. in 2017(20) found that those examining the relationship between religious
scoring high on religiosity were 54% less likely to involvement and family or marital stability (8).
report a lifetime history of PTSD (OR=0.46, 95% Of those, 68 (86%) reported significantly lower
CI=0.22-0.95) and were 70% less likely to report rates of divorce, greater marital satisfaction, less
current PTSD (OR=0.30, 95% CI=0.10-0.90). spouse abuse, less cheating on spouse, or greater
Longitudinal studies have reported similar likelihood of having a two-parent family in those
results such as that of Currier et al. in 2015 (21) who were more religious.
found that among U.S. veterans with severe
PTSD admitted to a rehabilitation facility, More recently, Li et al. in 2018 (24) at the
religious involvement assessed on admission Harvard School of Public Health followed 66,444
predicted significantly lower PTSD severity at initially married women over a 14-year period,
discharge, independent of baseline PTSD finding a 41-47% reduction in likelihood of
severity. divorce or separation among those attending
religious services at least weekly or more than
Psychological Well-Being. weekly at baseline (HR=0.59, 95% CI= 0.50-0.69,
In the systematic review of Koenig et al in 2012 for weekly attendance; HR=0.53, 95% CI=0.42-
(8), a total of 326 peer-reviewed academic 0.67, for greater than weekly).
research studies examining the relationship
between religiosity and psychological well-being DISCUSSION
were identified. Of those, 256 (79%) reported
that religious involvement was related to greater Understanding the Religion-Mental Health
happiness, higher life satisfaction, and other Relationship
indicators of psychological well-being, whereas
only 3 of those 326 studies (<1%) reported Figure 1 presents a theoretical causal model that
significantly lower well-being among the more describes how religious involvement may affect
religious. mental and social health (9 Koenig et al., 2023,
Chapter 16). As this model illustrates, religious
Recent studies conducted since that review involvement (beliefs and practices) influence
support these findings (9) Koenig et al., 2023). mental and social health across the lifespan,
The same is true for having meaning and beginning with the religious involvement of
purpose in life, which those with mental health parents prior to conception (better health
problems often lack. The 2012 review mentioned behaviors, better mental health). Next, maternal
earlier (8) found that 42 of 45 (93%) quantitative religiosity (less alcohol/drug use, greater marital
studies reported greater meaning and purpose stability, lower stress levels) has an influence on
among those who scored higher on religious in-utero brain development. After the birth of
measures. Likewise, religious involvement is the child, the religiosity of parents influences the
related to both greater hope (29 of 40 studies or development of basic trust in the child because
73%) and greater optimism (26 of 32 studies or all major world religions emphasize the love and
81%). More recent research using larger samples care for children. In the teenage years, religious
and better methodology has reported similar parents are more likely to monitor their
findings, including studies conducted in young teenagers, requiring them to behave in an ethical
adults (15, 22, 23) (Chen et al., 2018; Chen et al., and moral manner, thereby reducing
2021; Upenieks & Liu, 2022). alcohol/drug use, teenage pregnancy,
delinquency, etc.). In the adult years, religion
Social Support. enhances the use of healthier coping behaviors,
Having adequate social support is crucial for avoidance of life stressors, and promotion of
mental health, especially when life stressors prosocial behaviors, thereby enhancing mental
begin to threaten well-being. The systematic health. Finally, as individuals reach old age and
review of 2012 (8) identified 74 studies that the end of life, religious beliefs that provide
examined the relationship between religiosity meaning, hope, and psychological resilience in
and social support. Of those, 61 (82%) found that the face of disability and death.
greater religious involvement was associated
with more social support and a greater quality Religiously-Integrated Psychotherapies
of support that persisted during stressful life
circumstances. Likewise, the same systematic The development of religiously-integrated
review identified 79 quantitative studies psychotherapies and their testing in randomized

4 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

 Figure 1. Theoretical Causal Model of the Relationship between Religious
Involvement & Mental/Social Health. (Adapted from Koenig et al., 2023 (9)

controlled trials and in single-group psychological outcomes (g=0.74, p < 0.000,

experimental studies has enabled the use of indicating a large treatment effect). When
evidence-based practices whereby clinicians compared to any form of secular
utilize the religious beliefs of patients in help psychotherapy, effects were likewise superior (g
them recover from major life changes and to = 0.33, p < 0.001, indicating a moderate effect
endure the stress of chronic mental illness. size). In more rigorous additive studies (where
R/S was added to a standard treatment and then
One early study of 406 patients with persistent compared with the standard treatment), R/S‐
mental illness at a Los Angeles County mental accommodated psychotherapies were equally
health facility (the majority with schizophrenia effective to standard approaches (g = 0.13, p =
or schizoaffective disorder), found that more 0.258, indicating only a small level of
than 80% of patients indicated they used religion superiority).
to help them cope and 30% indicated that
religion was “the most important factor that kept Two religiously / spiritually-integrated
them going” ( 25 Tepper et al., 2001). psychotherapies were reviewed: Religiously-
Integrated Cognitive Behavioral Therapy
Captari et al. in 2018) (12) summarized the (RCBT) for depression/anxiety and
results of 97 randomized controlled trials (the Spiritually/Religiously Integrated Cognitive
majority targeting depression or psychological Processing Therapy (SICPT) for the treatment
distress) involving 7,181 subjects that examined of moral injury and PTSD.
the efficacy of tailoring psychotherapy to
patients’ Religious/Spirituality beliefs (i.e., R/S- Religiously-Integrated Cognitive Behavioral
adapted psychotherapy). Compared to no Therapy.
treatment (R/S), R/S‐adapted psychotherapy
resulted in significant improvement in clients’ This is a 10-session structured religiously-

5 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

integrated form of cognitive behavioral therapy Scale-Short Version (31 Koenig et al., 2018; 32
(RCBT) for the treatment of depression and Koenig et al., 2019).
anxiety (26 Koenig et al., 2015; (27 Pearce et al.,
2015; (28 Pearce, 2016). For psychiatrists and licensed behavioral health
specialists, we have developed a spiritually-
When testing RCBT against conventional CBT in integrated version of Cognitive Processing
a randomized controlled trial, the effect size Therapy (CPT) directed at treating Moral Injury
(Cohen’s d) of the intervention at the trial’s and Post- Traumatic – Stress Disorder resulting
primary endpoint following ten 50-minute from combat trauma that could easily be
sessions of RCBT was 3.02 compared to an effect adapted for non-military settings. This
size of 2.39 for conventional CBT (Koenig, 2018, intervention is broadly spiritual, but there are
p 270 (13). Note that any effect size (Cohen’s d) also religion-specific modules for addressing MI
greater than 0.80 is considered a “large” in those from Christian, Jewish, Muslim, Buddhist,
treatment effect. Thus, RCBT had an effect that and Hindu faith traditions. This approach uses a
would be considered nearly 4 times larger than CPT framework. CPT is one of two standard
the threshold for a large treatment effect, psychotherapeutic approach to PTSD in the U.S.
reducing depressive symptoms by nearly 50%. Veterans Administration Health System and the
Department of Defense (along with Prolonged
Spiritually/Religiously Integrated Cognitive Exposure therapy) (33) VA/DoD, 2017).
Processing Therapy for Moral Injury. Spiritually Integrated Cognitive Processing
According to a definition provided by Litz et al. Therapy (SICPT) addresses each of the 10 core
2009 (29), “moral injury involves an act of symptoms of moral injury: guilt, shame, moral
transgression that creates dissonance and concerns, feelings of betrayal, loss of trust, loss
conflict because it violates assumptions and of meaning and purpose, difficulty forgiving,
beliefs about right and wrong and personal self-condemnation, religious/spiritual struggles,
goodness…” In other words, moral injury (MI) and loss of religious faith.
involves inner emotional conflict over the
transgression of moral or ethical values. Moral SICPT is a 12-session manual-based structured
Injury is a relatively new syndrome (yet actually one-on-one intervention that is delivered over 6
very old) that often occurs in the setting of to 12 weeks (34) (Koenig et al., 2017; 35 Pearce et
severe psychological trauma, such as Post- al., 2018). By reducing MI, the goal is to decrease
Traumatic Stress Disorder (PTSD). However, MI trauma symptoms and comorbid mental and
is considered a distinct syndrome that is physical health conditions (e.g., PTSD,
separate from PTSD (30) Koenig et al., 2020b). depression, anxiety, substance abuse,
relationship problems, chronic pain, disability,
Although initially reported in active-duty etc.). We are currently conducting a single-
military personnel or veterans involved in group experimental study at Duke University to
combat operations where moral/ethical values demonstrate the efficacy of SICPT, and initial
were transgressed due to killing, immoral results have been quite promising (36) (O’Garo
actions towards the enemy, etc., MI also occurs in & Koenig, 2023; 37 Koenig, Carey & Zaben et al
first responders who are repeatedly exposed to 2023).
trauma (police, firemen, or emergency medical
personnel), civilians experiencing severe trauma Good Clinical Practice.
(e.g., rape, physical assault), and even
healthcare professionals (often the cause of Whether or not psychiatrists implement one of
burnout). MI includes psychological symptoms the religiously-integrated psychotherapies
(guilt, shame, feeling betrayed, loss of trust, self- above, all mental health professionals should be
condemnation), spiritual symptoms (loss of practicing in a way that respects and supports
meaning and purpose, difficulty forgiving, the religious beliefs and practices of patients.
miscellaneous moral concerns), and religious This begins by taking a mental health spiritual
symptoms (religious struggles and loss of history (Table 1).
religious faith) (9) Koenig et al., 2023).
Psychometrically reliable and valid measures
exist that can be used to assess these symptoms,
particularly the 10-item Moral Injury Symptom

6 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

Table 1. The Mental Health Spiritual History (13) (Koenig, 2018, p. 342)
1. Do you consider yourself religious or spiritual person or neither?

2. If religious or spiritual, ask: Explain to me what you mean by that?

3. If neither religious nor spiritual, ask: Was this always so?

3a.If no, ask: When did that change and why? [end the spiritual history for now, although may
return to it after therapeutic relationship established]

4. Do you have any religious or spiritual beliefs that provide comfort?

4a. If yes, ask: Explain to me how your beliefs provide comfort.
4b.If no, ask: Is there a particular reason why your beliefs do not provide comfort?

5. Do you have any religious or spiritual beliefs that cause you to feel stressed?
5a. If yes, ask: Explain to me how your beliefs cause stress in your life.

6. Do you have any spiritual or religious beliefs that might influence your willingness to take
medication, receive psychotherapy, or receive other treatments that may be offered as part of
your mental health care?

7. Are you an active member of a faith community, such as a church, synagogue, or mosque?
7a. If yes, ask: How supportive has your faith community been in helping you?
7b. If no, ask: Why has your faith community not been particularly supportive?

8. Tell me a bit about the spiritual or religious environment in which you were raised. Were either of
your parents religious?

9. During this time as a child, were your experiences positive or negative ones in this environment?

10. Have you ever had a significant change in your spiritual or religious life, either an increase or a
decrease? If yes, ask: Tell me about that change and why you think the change occurred.

11. Do you wish to incorporate your spiritual or religious beliefs in your treatment?
11a. If yes, ask: How would you like this to be done?

12. Do you have any other spiritual needs or concerns that you would like addressed in your
mental health care?

13. “Have you ever had a significant change in your spiritual or religious life, either an increase or a
decrease?”

14. “Do you wish to incorporate your spiritual or religious beliefs in your treatment?” If yes, ask:
“How would you like to do this?”

15. “Do you have any other spiritual needs or concerns that you would like addressed in your
mental health care?”

7PJP
· PJP
2021
2023
· Volume
· Volume
2 (1-2)
4 (1-2)
· ISSN
· ISSN 2980-4884
Many major professional psychiatric 12.Captari LE, Hook JN, Hoyt W, Davis DE, McElroy‐Heltzel SE,
Worthington Jr EL. Integrating clients’ religion and spirituality within
associations now recommend the taking of a psychotherapy: A comprehensive meta‐analysis. Journal of Clinical
spiritual history as part of good clinical practice, Psychology. 2018; 74(11): 1938-1951.
including the World Psychiatric Association (38) 13.Koenig HG. Religion and Mental Health: Research and Clinical
Applications. San Diego, CA: Academic Press; 2018.
Moreira‐Almeida et a l., 2016), the American 14.Marques A, Ihle A, Souza A, Peralta M, de Matos MG. Religious-
Psychiatric Association (39) APA,1990; (40) Dike based interventions for depression: A systematic review and meta-
analysis of experimental studies. Journal of Affective Disorders. 2022
et al., 2022), and the Royal College of
Jul 15; 309: 289–296.doi: 10.1016/j.jad.2022.04.126. Epub 2022 Apr
Psychiatrists (41) Cook, 2013). 29. PMID: 35500682
15.Chen Y, Kim ES, VanderWeele TJ. Religious-service attendance and
subsequent health and well-being throughout adulthood: Evidence
CONCLUSION from three prospective cohorts. International Journal of
Based on a growing volume of quantitative Epidemiology. 2021 Jan 23; 49(6): 2030-2040.
16.VanderWeele TJ, Li S, Tsai AC, Kawachi I. Association between
research, religious involvement (in general) is
religious service attendance and lower suicide rates among US
related to better mental, social, and behavioral women. JAMA Psychiatry. 2016; 73(8): 845-851.
health, and improves these aspects of health 17.Chen Y, Koh HK, Kawachi I, Botticelli M, VanderWeele TJ. Religious
service attendance and deaths related to drugs, alcohol, and suicide
over time in prospective cohort studies. among US health care professionals. JAMA Psychiatry. 2020 May 6;
Religiously-integrated psychotherapeutic 77(7): 737-744.
interventions have been developed for many 18. Kleiman EM, Liu RT. Prospective prediction of suicide in a
nationally representative sample: religious service attendance as a
disorders, especially depression, anxiety, PTSD, protective factor. The British Journal of Psychiatry. 2014; 204(4):
and other forms of internal emotional distress 262-266.
19.Wu A, Wang JY, Jia CX. Religion and completed suicide: A meta-
generated by transgressing moral values. As
analysis. PloS One. 2015; 10(6): e0131715.Available from:
part of good clinical practice, psychiatrists https://doi.org/10.1371/journal.pone.0131715.
should consider learning about the religious and 20.Sharma V, Marin DB, Koenig HG, Feder A, Iacoviello BM, Southwick
SM, et al. Religion, spirituality, and mental health of US military
spiritual beliefs of patients by taking a spiritual veterans: Results from the National Health and Resilience in Veterans
history, and if patients are religious and prefer Study. Journal of Affective Disorders. 2017 Aug 1; 217: 197-204. doi:
10.1016/j.jad.2017.03.071. Epub 2017 Apr 11. PMID: 28415007.
to integrate their religious/spiritual beliefs into
21.Currier JM, Holland JM, Drescher KD. Spirituality factors in the
therapy, consider implementing a prediction of outcomes of PTSD treatment for US military veterans.
religiously/spiritually-integrated form of Journal of Traumatic Stress. 2015; 28(1): 57-64.
22.Chen Y & VanderWeele TJ. Associations of religious upbringing
psychotherapy or supportive care. with subsequent health and well-being from adolescence to young
adulthood: an outcome-wide analysis. American Journal of
Epidemiology. 2018;187(11): 2355-2364.
REFERENCES
1. Koenig HG. Concerns about measuring “spirituality” in research. 23.Upenieks L & Liu Y. Does religious participation predict future
Journal of Nervous and Mental Disease. 2008; 196(5): 349-355. expectations about health? Using a life course framework to test
2. Tsuang MT & Simpson JC. Commentary on Koenig (2008): multiple mechanisms. Journal of Religion and Health. 2022; 61(3):
“Concerns about measuring ‘spirituality’ in research.” Journal of 2539-2568.
Nervous and Mental Disease. 2008; 196(8): 647-649. 24.Li S, Kubzansky LD, VanderWeele TJ. Religious service attendance,
3. Garssen B & Visser A. Spiritual wellbeing predicting depression: Is divorce, and remarriage among US nurses in mid and late life. PloS
it relevant? Journal of Behavioral Medicine.2016; 39(2): 369-369. One. 2018; 13(12): e0207778. Available from:
4. Garssen B, Visser A, de Jager Meezenbroek E. Examining whether https://doi.org/10.1371/journal.pone.0207778.
spirituality predicts subjective well-being: How to avoid 25. Tepper L, Rogers SA, Coleman EM, Malony HN. The prevalence of
tautology. Psychology of Religion and Spirituality. 2016; 8(2): 141- religious coping among persons with persistent mental illness.
148. Psychiatric Services. 2001; 52(5): 660-665.
5. King M, Marston L, McManus S, Brugha T, Meltzer H, Bebbington 26. Koenig HG, Pearce MJ, Nelson B, Shaw SF, Robins CJ, Daher NS,
P. Religion, spirituality and mental health: results from a national et al. Religious vs. conventional cognitive behavioral therapy for
study of English households. British Journal of Psychiatry. 2013; major depression in persons with chronic medical illness: A pilot
202(1):68-73. randomized trial. Journal of Nervous and Mental Disease. 2015;
6. Leurent B, Nazareth I, Bellón-Saameño J, Geerlings MI, Maaroos 203(4): 243-251.
H, Saldivia S, et al. Spiritual and religious beliefs as risk factors for 27.Pearce MJ, Koenig HG, Robins CJ, Nelson B, Shaw SF, Cohen HJ, et
the onset of major depression: an international cohort study. al. Religiously integrated cognitive behavioral therapy: A new method
Psychological Medicine.2013; 43(10): 2109-2120. of treatment for major depression in patients with chronic medical
7. Upenieks L & Ford-Robertson J. Changes in spiritual but not illness. Psychotherapy. 2015; 52(1): 56-66.
religious identity and well-being in emerging adulthood in the 28.Pearce MJ. Cognitive Behavioral Therapy for Christians with
United States: Pathways to health sameness? Journal of Religion Depression: A Practical Tool-Based Primer. Conshohocken, PA:
and Health. 2022 Dec; 61(6): 4635-4673. Templeton Foundation Press; 2016.
8. Koenig HG, King DE, Carson VB. Handbook of Religion and Health. 29.Litz BT, Stein N, Delaney E, Lebowitz L, Nash WP, Silva C, et al.
2nd ed. New York, NY: Oxford University Press; 2012. Moral injury and moral repair in war veterans: A preliminary model
9. Koenig HG, VanderWeele TJ, Peteet JR. Handbook of Religion and and intervention strategy. Clinical Psychology Reviews. 2009 Dec;
Health. 3rd ed. New York, NY: Oxford University Press; 2023. 29(8): 695-706.
10. Koenig HG, Al-Zaben F, VanderWeele TJ. Religion and psychiatry: 30.Koenig HG, Youssef NA, Ames D, Teng EJ, Hill TD. Examining the
Recent developments in research. British Journal of Psychiatry overlap between moral injury and PTSD in US veterans and active
Advances. 2020 Apr; 26(5): 262-272. duty military. Journal of Nervous and Mental Disease. 2020 Jan;
11. Balboni TA, VanderWeele TJ, Doan-Soares SD, Long KN, Ferrell 208(1): 7-12.
BR, Fitchett G, et al. Spirituality in serious illness and health. 31.Koenig HG, Ames D, Youssef NA, Oliver JP, Volk F, Teng EJ, Pearce
Journal of the American Medical Association.2022; 328(2): 184- M. Screening for moral injury: the moral injury symptom scale–
197. military version short form. Military Medicine. 2018; 183(11-12): e659-
e665.

8 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

32. Koenig HG, Youssef NA, Pearce M. Assessment of moral injury in
veterans and active duty military personnel with PTSD: A review.
Frontiers in Psychiatry. 2019 Jun 28; 10: 443.
33. VA/DoD (2017). VA/DoD Clinical Practice Guidelines for the
Management of Posttraumatic Stress Disorder and Acute Stress
Disorder, Version 3.0. [cited 2022 Dec 15] Available from: Boland R,
Verduin M, Ruiz P, Shah A, Sadock B. Kaplan and Sadock’s Synopsis of
Psychiatry. 12th ed. Wolters Kluwer; 2022. p 1396-1397.
34.KKoenig HG, Boucher NA, Oliver RJP, Youssef N, Mooney SR,
Currier JM, Pearce M. Rationale for spiritually oriented cognitive
processing therapy for moral injury in active duty military and
veterans with posttraumatic stress disorder. Journal of Nervous and
Mental Disease. 2017; 205(2): 147-153.
35. Pearce M, Haynes K, Rivera NR, Koenig HG. Spiritually integrated
cognitive processing therapy: A new treatment for post-traumatic
stress disorder that targets moral injury. Global Advances in Health
and Medicine. 2018 Feb 20; 7:
2164956118759939.doi.10.1177/2164956118759939.eCollection
2018. PMID: 29497585; PMCID: PMC5824894.
36.O’Garo KN, Koenig HG. Spiritually-integrated cognitive processing
therapy for moral injury in the setting of PTSD: Initial evidence of
therapeutic efficacy. Journal of Nervous and Mental Disease, in
submission, 2023. Submitted to J of Nervous & Mental Disease.
Forthcoming 2023.
37.Koenig HG, Carey LB, Al Zaben F. Moral Injury: A Handbook for
Military Chaplains. Seattle, WA: Amazon/Kindle; 2023.
38.Moreira‐Almeida A, Sharma A, van Rensburg BJ, Verhagen PJ,
Cook CC. WPA position statement on spirituality and religion in
psychiatry. World Psychiatry. 2016; 15(1): 87-88.
39.APA. American Psychiatric Association Committee on Religion and
Psychiatry: Guidelines regarding possible conflict between
psychiatrists’ religious commitments and psychiatric practice.
American Journal of Psychiatry. 1990 Apr; 147(4):542.
40.Dike CC, Briz L, Fadus M, Martinez R, May C, Milone R, et al.
Religion, spirituality, and ethics in psychiatric practice. Journal of
Nervous and Mental Disease. 2022 Aug 1; 210(8): 557–563.

9 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

 PJP SPECIAL ARTICLE

EXAMINING MENTAL HEALTH AND DIVERSITY AND

COLLABORATING TOWARDS IMPROVED MENTAL
HEALTH FOR ALL
ANTHONY P. S. GUERRERO, M.D.*

On behalf of all of our Hawai‘i-based colleagues Following the Philippine-American War, the
with ties to the Philippines, we send warm Philippines became an American colony.
greetings and aloha to all. In this article, we aim Between 1906 to 1946, Filipino plantation workers
to: 1) highlight the importance of understanding were heavily recruited, based on acceptance of
culture and history in optimizing individual and low wages, relative inexperience with labor
populational mental health and in addressing strikes, status as U.S. subjects, and reputation for
mental health disparities; 2) review studies from industriousness. Filipinos joined the many other
Hawai‘i investigating the potential role of ethnocultural groups who had come to Hawai‘i in
acculturative stress in indigenous and immigrant earlier waves of immigration, including the
populations; and 3) propose international Euro-Americans, Chinese, Portuguese, Japanese,
collaborations and friendships to understand Okinawans, Hispanics, and Koreans.
and provide care for the people we serve.
In 1965, the Immigration and Nationality Act
The Philippines and Hawai‘i have enjoyed close allowed petitioning of families. During this time,
ties throughout history. The languages spoken in there was a significant immigration of Filipino
the Philippines and indigenously in Hawai‘i are nurses. The modern healthcare system of the
members of the Austronesian language family. United States would likely not be what it is today
They reflect the migration of ancient seafarers if not for this wave of immigration. An
with highly advanced boatbuilding and overwhelming majority of care home operators
navigational skills to maritime Southeast Asia in Hawai‘i are Filipino.
and remote regions of the Pacific and Indian
Oceans. Hawai‘i’s capital city of Honolulu is Filipinos are concentrated in many of the
separated from the Philippines’ capital city of geographic areas in Hawai‘i where plantations
Manila by approximately 5296 miles, a 10-hour existed, including the Waipahu-‘Ewa area of the
plane ride, or by readily accessible island of O‘ahu and the island of Lāna‘i. Pure or
instantaneous two-way synchronous part-Filipinos constitute a sizable non-majority
communications (that made our participation in proportion of Hawai‘i’s population. In
the annual convention possible). comparison with other ethnic groups in Hawai‘i,
Filipinos have below average median family
The history of Filipinos in Hawai‘i is briefly incomes and rates of completion of a bachelor’s
reviewed by Guerrero, Bayola, and Ona. (1) degree.
Spain ceded the Philippines to the United States
in 1898.

This manuscript is based on the author’s presentation, “Mental Health and Diversity in Hawai‘i:
Addressing Violence and Delinquency, Suicide, and Other Risks,” at the 49th annual
convention of the Philippine Psychiatric Association. 1/17/2023. Novotel Manila, Araneta
Center.
*University of Hawai‘i John A. Burns School of Medicine, Department of Psychiatry
[email protected] 10 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884
Filipinos may be over-represented in gang They were a prosperous and thriving people,
membership on the island of O‘ahu. (3) Among numbering approximately 800,000, prior to
adolescents in Hawai‘i, Filipino, Native Hawaiian, regular Western contact beginning in 1778, when
and Samoan youth may have higher rates of Captain Cook landed. (9) Very tragically, the
disruptive behavior than Japanese youth. (4) population of pure Native Hawaiians had
declined, through foreign-introduced diseases
In a study surveying a school-based sample of and related adversities, by over 90% within 100
Filipino youth in Hawai‘i, low SES correlated with years thereafter. The Hawaiian government was
poor school performance and behavioral and illegally overthrown in 1893, and Hawai‘i was
emotional difficulties. (5) On the other hand, illegally annexed in 1898 by the US government,
family support and higher SES appeared to who subsequently apologized in 1993.
protect against academic, behavioral and
emotional difficulties. Indirect measures of Among Native Hawaiian adolescents in Hawai‘i,
cultural identification, such as speaking a who appear to be at high risk for suicide,
language other than English or learning one’s Hawaiian cultural affiliation appeared to be a
genealogy, appeared to protect against marker for suicide attempts. (10) In the context
substance abuse and poor school performance. of historical colonization and trauma,
Congruent with these findings, in a qualitative acculturative stress might be the mediating
study involving focus groups, identified risk variable between indigenous cultural
factors for violence among Filipino youth in identification and psychopathology. Goebert
Hawai‘i included low ethnic pride, lack of adult and colleagues (11) have highlighted the
supervision, and acculturative stress, while importance of considering the impact of
identified protective factors included religion historical trauma and colonization in addressing
and connections to family and Filipino culture. the health and mental healthcare needs of Native
(6) Hawaiians. They further emphasize, in suicide
prevention, the importance of culturally
In subsequent study surveying a school-based informed and culturally embedded programs
sample of Filipino youth in Hawai‘i, delinquent that enhance connections to people and place
behavior correlated positively with acculturative and that inspire hope.
stress, low cultural identification and adverse
peer influences; and negatively with total score It is possible that higher affiliation with one’s
on a Filipino Culture Scale. (7) Further analysis heritage culture among Filipino youth in Hawai‘i,
suggested that, in linking low cultural who represent a largely voluntary immigrant
identification to delinquent behavior, population, may not necessarily lead to
absent/ineffective adults and adverse peer acculturative conflict with either “Local” or
influences might be more important variables “American” culture as measured in these
compared to low self-esteem and less religiosity. aforementioned studies. As Bhugra (12) explains,
The authors concluded that, to be effective, cultural identity, if it contributes to discordance
efforts to prevent delinquency by enhancing between the individual’s social characteristics
Filipino youths' cultural connectedness may also and the surrounding population’s characteristics,
need to enhance family connectedness, thereby may be a risk factor for distress. On the other
counterbalancing adverse peer influences. hand, if it contributes to concordance with the
individual’s social characteristics and the
The authors further suggested that cultural surrounding population’s characteristics, it may
identification may or may not always serve as a be a protective factor against distress.
strong mental health protective factor,
depending on the historical context and on its Berry (13) describes four patterns of cultural
impact upon other risk or protective factors. interfacing, according to degrees of
Other studies from Hawai‘i, particularly those maintenance of heritage culture and seeking of
focused on indigenous Hawaiian mental health, relationship with surrounding society:
may illustrate this point. integration, i.e., high maintenance of heritage
culture and high seeking of relationship with
The indigenous Hawaiians were seafarers who surrounding society; separation (high, low);
likely settled from the Northern Outlier assimilation (low, high); and marginalization
Polynesian group of islands. (8) (low, low).

11 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

On the societal level, the analogous strategies are Extending the knowledge learned above to
multiculturalism, segregation, melting pot, and care for other globally mobile populations
exclusion. Bicultural competence may be a key likely to be at high risk for acculturative
element of psychological well-being, and stressors, including overseas workers and
integration and multiculturalism may facilitate seafarers; people displaced by armed
social solidarity. conflict; victims of violence, genocide, and
trafficking; people displaced by climate
The likely pattern of cultural interfacing is change, famine, and other loss of homeland;
influenced as much by societal factors expatriates; and short-term visitors.
(facilitating and positive, or otherwise) as by Sharing and optimizing models for
individual factors. McDermott and Andrade (14) populational mental healthcare, tailored
have described that, in contrast to the melting towards the needs of indigenous people and
pot model that assumes assimilation and others who likely face multiple barriers in
homogenization, the ‘Hawaiian Stewpot’ is based accessing healthcare.
on accommodation and interaction, and is Overall recognizing the value of our multi-
grounded in the indigenous Hawaiian cultural cultural stew-pots and striving together
concepts of inclusiveness, including the values of towards a just society that addresses and
aloha, lōkahi, and ‘ohana. Places like Hawai‘i, prevents cultural and historical traumas.
with a long history of multiculturalism,
intermarriage, and high proportions of mixed Following the convention’s theme of “Expanding
ethnicity individuals, appear to be less likely to the Clinical Perspective of the Psychiatrist,” we
cultivate racism and race-based ideologies. (15) must embrace our roles as partners and
In this regard, it appears that the Philippines, advocates for improved mental health in a
described to have both “diversity in unity” and world that is facing unprecedented threats that
“unity in diversity,” (16) may share with Hawai‘i can only be addressed through partnership and
similar ingredients for an analogous type of stew through finding synergies notwithstanding
pot. distance and diversity. We heartily salute the
Philippine Psychiatric Association for its noble
Guerrero and Andrade (17) have recommended work, and we welcome, with open arms, a future
that assessment of larger societal culture and its of trans-oceanic partnership.
interface with individual/family culture is
important in understanding risk for
acculturative stress. They propose that societies
find strengths in diversity and work to eliminate
discrimination and marginalization – just as we
would any other type of trauma or adverse
childhood event that adversely affects
development.

Towards these ends, we propose that, on both

sides of the ocean, our teams can collaborate on
improving psychiatric care for our patients, who
represent various aspects of diversity in terms of
culture, history, and movement and migration
throughout the world. Specific initiatives we
could work on together include:

Facilitating connections and mutual learning

among colleagues who care for immigrant
populations and who need a strong
appreciation of both Filipino and non-
Filipino cultures to better understand the
adjustment and acculturation that our
patients face, and to optimally nurture the
strengths that cultural affinities may confer.

12 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

REFERENCES

1. Guerrero APS, Bayola R, Ona C. The Filipinos. In: Andrade NN,

McDermott Jr JF, editors. People and cultures of Hawai‘i: the
evolution of culture and ethnicity. Honolulu: University of
Hawai‘i Press; 2011. p. 201-219.
2. Guerrero APS, Chock S, Lee AK, Sugimoto-Matsuda J, O’Kelly
AS. Mental health disparities, mechanisms, and intervention
strategies: perspective from Hawai‘i. Curr Opin Psychiatry.
2019 Nov;32(6): 549-556.
3. Chesney-Lind M, Rockhill A, Marker N, Reyes H. Gangs and
delinquency: Exploring police estimates of gang
membership. Crime L & Soc Change. 1994; 21: 201-228.
4. Mayeda DT, Hishinuma ES, Nishimura ST, Garcia-Santiago O,
Mark GY. Asian/Pacific Islander youth violence prevention
center: interpersonal violence and deviant behaviors among
youth in Hawai‘i. J Adolesc Health. 2006 Aug; 39(2): 276.e1-
11.
5. Guerrero AP, Hishinuma ES, Andrade NN, Nishimura ST,
Cunanan VL. Correlations among socioeconomic and family
factors and academic, behavioral, and emotional difficulties
in Filipino adolescents in Hawai‘i. Int J Soc Psychiatry. 2006
Jul; 52(4): 343-59.
6. Cunanan VL, Guerrero AP, Minamoto LY. Filipinos and the
myth of model minority in Hawai‘i: A pilot study. Journal of
Ethnic and Cultural Diversity in Social Work. 2007 Feb
20;15(1-2):167-92.
7. Guerrero AP, Nishimura ST, Chang JY, Ona C, Cunanan VL,
Hishinuma ES. Low cultural identification, low parental
involvement and adverse peer influences as risk factors for
delinquent behaviour among Filipino youth in Hawai‘i. Int J
Soc Psychiatry. 2010 Jul; 56(4): 371-88.
8. Wilson WH. East Polynesian Subgrouping and Homeland
Implications Within the Northern Outlier–East Polynesian
Hypothesis. Oceanic Linguistics. 2021; 60(1): 36-71.
9. Andrade NN, Bell CK. The Hawaiians. In: McDermott JF,
Andrade NN, editors. People and cultures of Hawai‘i.
Honolulu: University of Hawai‘i Press; 2011. p. 1-31.
10. Yuen NY, Nāhulu LB, Hishinuma ES, Miyamoto RH. Cultural
identification and attempted suicide in Native Hawaiian
adolescents. J Am Acad Child Adolesc Psychiatry. 2000 Mar;
39(3): 360-7.
11. Goebert D, Alvarez A, Andrade NN, Balberde-Kamalii J,
Carlton BS, Chock S, et al. Hope, help, and healing: Culturally
embedded approaches to suicide prevention, intervention
and postvention services with native Hawaiian youth.
Psychol Serv. 2018 Aug; 15(3): 332-339.
12. Bhugra D. Cultural identities and cultural congruency: a new
model for evaluating mental distress in immigrants. Acta
Psychiatr Scand. 2005 Feb; 111(2): 84-93.
13. Berry JW. Integration and multiculturalism: Ways towards
social solidarity. Papers on Social Representations. 2011 Mar
15;20(1):2-1.
14. McDermott JF, Andrade NN. Introduction. In: Andrade NN,
McDermott Jr JF, editors. People and cultures of Hawai‘i: the
evolution of culture and ethnicity. Honolulu: University of
Hawai‘i Press; 2011. p. xi-xxiii.
15. Velasquez-Manoff M. Want to Be Less Racist? Move to
Hawai‘i. The New York Times. 2019 Jun 28.
16. Tan, SK. A History of the Philippines. Quezon City: The
University of the Philippines Press; 2008. p. 5.
17. Guerrero AP, Andrade JK. Cultural psychiatry as the basic
science of addressing health and mental health disparities.
In: Hodes M, Gau SS-F, de Vries PJ, editors. Starting At the
Beginning: Laying the Foundation for Lifelong Mental Health.
London: Elsevier Academic Press; 2020. p. 31-42.

13 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

 PJP SPECIAL ARTICLE

THE USE OF AN ILLUMINATIVE EVALUATION APPROACH IN THE

IMPLEMENTATION ASSESSMENT OF A HIGHER EDUCATION
INSTITUTE COURSE OFFERED IN THE PANDEMIC

EVANGELINE B. DELA FUENTE, MD, MHA, MHPED

DEPARTMENT OF PSYCHIATRY AND BEHAVIORAL MEDICINE
COLLEGE OF MEDICINE
UNIVERSITY OF THE PHILIPPINES MANILA

ABSTRACT

While the regular evaluation of academic courses is an essential exercise for quality
assurance and improvement, among other purposes, the courses developed and offered
in the abrupt shift to remote learning during the pandemic merit monitoring and
evaluation. An implementation assessment is recommended and the use of an
Illuminative Approach is illustrated.

KEYWORDS: Illuminative Evaluation, Higher Education Assessment, Pandemic

INTRODUCTION environments and compatible with the learning

management system provided by the institution
Educational evaluation is important for many in time for the coming schoolyear. Hodges et al
reasons and there are many types. One type is (2020) termed these courses offered online in
an implementation assessment which provides response to a crisis or disaster as “emergency
practical data. This illustrates the conduct of an remote teaching” by universities working to
implementation assessment using the illuminative maintain instruction during the COVID-19
evaluation approach. pandemic and were expectedly meaningfully
The declaration of the COVID19 pandemic as a different from well-planned online learning
Public Health Emergency of International experiences. (1) While the regular evaluation of
Concern by the World Health Organization in academic courses is an essential exercise for
early 2020 brought on an unprecedented quality assurance and improvement, among
change in the manner of delivery of education. It other purposes, the courses developed and
necessitated an abrupt shift to remote learning offered in the abrupt shift to remote learning
in educational institutions which traditionally merit monitoring and evaluation.
offered in-person classes. With a narrow
preparation window and many faculty members Educational evaluation is defined as the
not familiar with online learning, training was determination of the worth of an educational
given to enable the faculty to develop revised offering through the systematic and scientific
versions of existing syllabi into pedagogically- collection, organization and interpretation of
informed, technology-enhanced modules that data. It is different from assessment which refers
may be used in online/blended learning to the measurement of how learners have

14 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

achieved the expected levels of competencies as In this way, the results of the program evaluation
a result of instruction (2 Sana, 2010). will have greater validity and reliability. The
implementation assessment can also serve as a
Worthen and Sanders (1987), outlines several formative assessment to guide necessary
purposes. First, an educational evaluation can midstream modifications and improvements in
appraise the quality of an academic offering. its present form.
Second, it can determine ways, by which it can
be systematically improved. Third, it can test Faithful implementation of a program can have
how known educational theories apply to the a significant impact on improving outcomes.
development of students. Fourth, it can aid in Implementation is generally defined as “a
credible, empirical decision-making about the specified set of planned and intentional activities
new educational offerings. And fifth, it can designed to integrate evidence-based practices
provide a cost-benefit analysis of the academic into real-world settings” ( 5 Vaughan & Albers
offering. (3) 2020). It is worth noting that it may not always
be possible to implement a program in real-
An appropriately done educational evaluation world settings as it was originally planned out
requires careful preparation as well as adequate due to unforeseen barriers or to implement it in
resources in terms of time, the design of a good the same way from one year to the next due to
quality evaluation instrument and adequate varying circumstances. Implementation
manpower. Another consideration is timing, that assessment can help in identifying and more
is, whether it will be done before the start of the accurately describing program components and
program as a diagnostic exercise to inform foster more accurate replication of the program.
decisions about learning outcomes, during the This will increase the chances of more
program as a formative evaluation to monitor consistently arriving at desired learning
the academic offering, or at the end as a outcomes year after year.
summative evaluation to provide judgement
about worth or merit. A final consideration is Consider a hypothetical example about a youth
who will conduct the evaluation. Formative program designed to promote team-building.
evaluations are best done by an internal Program evaluation by the original developers
evaluator who is a member of the program may yield significantly positive results. Without
being studied and would therefore be very implementation data, they may not realize that a
knowledgeable about it. An external evaluator large portion of the program success was due to
has the advantage of being impartial but the the quality of training and the interaction
disadvantage of not being as knowledgeable. between the trainers and the staff. Other groups
The choice will depend on the purpose of the that attempt to replicate the program may not
evaluation. realize the same outcomes (4 Duerden & Witt
2012). Assessing implementation provides
In general, then, an educational evaluation can insights into how programs work, how the
provide information on how effective a course components of the program actually help to
or program is in addressing learning outcomes produce the desired outcomes and why they
as well as specific directions on how it can be succeed or fail. Simply put, implementation
improved in a cost-effective manner using quality affects program outcomes (6 Durlak
credible, empirical data. It is ideally done on a 2008).
regular basis and can be useful when changes
are implemented in order to either inform the There are four major indicators of
change or determine the effect of the change. implementation quality: dosage, fidelity, quality
of delivery and acceptability. Dosage refers to
Duerden & Witt (2012) suggest that it is prudent the amount or frequency of interventions given
to do an assessment of how the program was which in the case of course offerings would be
actually being implemented, called an classes or course activities. Fidelity refers to the
implementation assessment, before conducting a degree to which an approach and support
full -scale program evaluation. (4) There is system are conducted as planned. Quality of
merit in first doing an assessment of how the implementation refers to the engagement and
program is actually being implemented to responsiveness of principals. Acceptability refers
determine if it is adherent to the program to the degree to which users and stakeholders of
design. an intervention accept its relevance and

15 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

importance. A participant-oriented approach such as the
Illuminative Model of Parlett and Hamilton
Furthermore, when implementing a program, which aims to “illuminate problems, issues and
providing ongoing support to teachers through significant program features” is one such model
coaching, workshops and supervision was shown (3 Worthen & Sanders 1987, p132). It has three
to have a substantial impact on student outcomes characteristic stages: 1) observation, in which the
(7 Albers & Pattuwage 2017). variables affecting the outcome of the program
are investigated, 2) the inquiry stage wherein
Duerden and Witt (2012) refers to similar questions are focused and directed in order to
dimensions to consider when looking at a arrive at a list of aspects important to the
concept that he considers to be integral to program in its context, and explanation wherein
implementation research, the concept of principles underlying the organization of the
program integrity which is defined as the program are determined and patterns of cause
and effect within its operations are delineated.
degree to which a program is implemented as
Within these three-stage framework, an
originally planned. The relevant dimensions to
information profile is compiled using data from
consider are adherence, exposure, quality of
primary sources such as observation, interviews,
delivery, and participant responsiveness. (4)
questionnaires, and secondary sources such as
documentary and background sources (Shapiro
Each one is defined as follows by Dane and
J & Reed B, 1982, Stufflebeam D & Shinkfield A,
Schneider (1998):
1985).

Adherence – the extent to which specified

The next section illustrates the use of the
program components were delivered as Illuminative Approach for the implementation
prescribed in manuals assessment of a course offered in the pandemic
as part f a formative evaluation.
Exposure – an index that may include any of the
following: (a) number of sessions implemented; Illustration of the use of the Illuminative
(b) the length of each session; or (c) the Approach in Implementation Assessment
frequency with which program techniques were
implemented The main objective of the assessment was to
determine whether the program was adherent to
Quality of delivery – a measure of qualitative the design and to elucidate what elements helped
aspects of program delivery that are not related or hindered program implementation and
to the implementation of prescribed content, quality toward the achievement of learning
such as implementor enthusiasm, leader outcomes. Table 1 provides an Evaluation Matrix,
preparedness, global estimates of session which guided the observation stage of the
effectiveness, and leader attitudes toward the evaluation.
program
Documents pertaining to a description of the
Participant responsiveness – a measure of course, the course schedule, the faculty guide
participant response to program sessions, which and assignment guide published in the learning
may include indicators such as levels of management system used by the faculty and the
participation and enthusiasm students for the course were used as data
When conducting an implementation assessment, sources. Attendance records of the faculty and
it is useful to find a suitable model to guide the of the students for the first semester were
process. While evaluation generally connotes the obtained as well.
use of objective, quantitative models, there is a
criticism that such evaluations do not provide Direct observation of a synchronous class
session was considered as a source of
explanations. There are alternative models,
information about how the activity was
which take account of the wider context, in which
conducted as well as the reactions of the faculty
educational programs function such that its
and the student participants but the presence of
primary concern is to describe and interpret
an outsider was anticipated to affect group
rather than to measure and predict.
process.

16 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

An alternative data source were recordings of The data analysis method employed for
post-processing meetings held online via qualitative data was Content Analysis. Guided by
videoconferencing platform. The recording was the evaluation questions, in vivo coding was done
transcribed to allow for analysis. with particular attention to use of time, faculty
attitude and delivery and student attitude and
The data sources were readily accessible from participation. Manifest analysis was employed in
the files of the course coordinator and the order to ensure closeness to the original
support staff as well as from the course site in meaning and contexts and ensure validity and
the learning management system. reliability of observed findings.

17 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

18 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884
The data analysis method employed for data pertaining to attendance was descriptive statistical
analysis.

19 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

The findings from the observation stage were 2. The course schedule allowed for flexibility,
used in the inquiry stage to help inform the which was of significance considering the
explanation stage. possibility of unforeseen class suspensions.
3. The group size of the faculty provides an
Dosage. The course as a whole was scheduled in advantage in terms of the availability of support
such a way that it was possible to accommodate when needed thereby giving the faculty a
with ease the unforeseen changes in the school confidence boost that each session will be
calendar. The time allotted per session however handled adequately.
was perceived to be inadequate. 4. The presence of a core group of faculty to
regularly provide guidance on the content and
Adherence. The course was delivered in the process of the course ensured that no concerns
sequence it had been designed to be delivered. were overlooked.
Quality of Delivery. The faculty seemed invested
in the process, were supportive of each other Among the areas for improvement were as
and conducted themselves candidly. Their follows:
attitude helped overcome some of the challenges 1. The activities and time allotment per session
encountered. need to be reviewed to ensure adequacy.
2. Faculty training and orientation especially in
Participant Responsiveness. The participants areas noted to adversely affect adherence
were noted to be more responsive than what was need to be improved.
expected from a first meeting and this can be 3. Information on verbal expressions peculiar
attributed in part to the design of the activity as to the incoming batch of students need to be
well as positive feedback from the previous included in the orientation to improve
batch of participants. communication between the faculty and the
students.
A focused group discussion with the faculty
yielded information relevant to the SUMMARY
improvement of course quality. The information gained from the internal
formative evaluation done using the illuminative
Among the strengths identified were as follows: approach provided an affirmation of the
1. The course content and design were elements of the program which contributed to
favorably received by students from program quality and yielded specific points for
different batches. improvement.

20 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

The yield from the evaluation conducted was of
practical value in guiding program
improvement and also enhanced readiness for a
more extensive program evaluation. It is thus
worthwhile for coordinators of educational
programs to consider using a similar approach
for their offerings.

REFERENCES
1. Hodges C, Moore S, Lockee B, Trust T, & Bond A. The difference
between emergency remote teaching and online learning. Educause
Review. 2020; 27.
2. Sana EA Ed. Teaching and Learning in the Health Sciences. Quezon
City: The University of the Philippines Press. 2010.
3. Worthen B & Sanders J. Educational Evaluation, Alternative
Approaches and Practical Guidelines. New York: Longman 1987.
4. Duerden M & Witt P. Assessing Program Implementation: What It Is,
Why It’s Important, and How to Do It. Journal of Extension.2012;
50(1) Retrieved from https://www.joe.org/joe/2012february/a4.php
5. Vaughan T & Albers B. Research to Practice – Implementation in
Education. Teacher (2020). Retrieved from
https://www.teachermagazine.com.au/articles/research-to-
practice-implementation-in-education
6. Durlak JA. Implementation Matters: A Review of Research on the
Influence of Implementation on Program Outcomes and the Factors
Affecting Implementation. American Journal of Community
Psychology. 2008; (41) 327-350 DOI: 10.1007/s10464-008-9165-0
7. Albers B & Pattuwage L. Implementation in Education: Findings from
a Scoping Review. Melbourne: Evidence for Learning. 2017.
Retrieved from http://www.evidenceforlearning.org.au/evidence-
informed-educators/implementation-in-education
8. Dane A & Schneider B. Program Integrity in Primary and Early
Secondary Prevention: Are Implementation Effects Out of Control?
Clinical Psychology Review. 2018; 18(1), pp 23-45.
9. Shapiro J & Reed B. Illuminative Evaluation: Meeting the Special
Needs of Feminist Projects. Paper presented at the Annual Meeting
of the American Educational research Association. March 1982
https://www.semanticscholar.org/paper/Illuminative-
Evaluation%3A-Meeting-the-Special-Needs-Shapiro-
Reed/0b6d46efb3de0287d84df178217269874701d7f0
10. Stufflebeam DL, Shinkfield AJ. Illuminative Evaluation: The Holistic
Approach. In: Systematic Evaluation. Evaluation in Education and
Human Services. (1985) vol 8. Springer, Dordrecht.
https://doi.org/10.1007/978-94-009-5656-8_9

21 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

 PJP ORIGINAL RESEARCH

A QUALITATIVE STUDY ON THE FACEBOOK EXPERIENCE OF

YOUNG ADULT UNIVERSITY STUDENTS IN METRO MANILA

CHRISTI ANNAH V. HIPONA, MD

UNIVERSITY OF THE PHILIPPINES - PHILIPPINE GENERAL
HOSPITAL
DEPARTMENT OF PSYCHIATRY & BEHAVIORAL MEDICINE

ABSTRACT

OBJECTIVES: The purpose of this study was to explore qualitatively Facebook engagement among
young adult university students and the perceived effects of their use.

METHODOLOGY: The study utilized a qualitative design using in-depth interview. Recruitment was
done using maximum variation purposive sampling via Facebook advertisement and posters within
the university. Interested students were asked to contact the principal investigator for an
interview schedule. Prior to interview, the respondents answered a socio-demographic
questionnaire.

RESULTS: Among the 19 students, the average time spent on social media was 4.3 hours or 260
minutes. On Facebook, specifically, the average time spent daily was 2.9 hours or 176 minutes.
Positive and negative experiences when viewing Facebook posts was found to be influenced by
the level of closeness between the student who posted and the reader. Commemoration posts by
close friends elicited happiness and benign envy. Factors that point to a positive experience
include positive social comparison, ease of communication and purpose of use, especially
academics. However, negative experiences also included witnessing meanness online and reading
about opposing views on sociopolitical issues, which led to depressive symptoms. Negative social
comparison also led to feelings of envy and sadness, which the respondents described to be more
severe in adolescence than in young adulthood.

CONCLUSION: The study explored how social media, especially Facebook, has shaped the way in
which people engaged with the world. Positive experiences were related to the level of closeness
of relationship while negative experiences were mostly due to negative encounters with friends
and the general tone of the feed. The study also determined that experiential change from
adolescent to young adulthood influence their perception of Facebook.

KEYWORDS: Facebook, Young Adults, University Students, Philippines

22 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

INTRODUCTION Factors for depression and anxiety included
frequent online social comparison, negative
Filipino young adults are known to have the perceived interaction quality, addictive use and
highest time spent on social media, especially rumination.
Facebook. However, there is insufficient data in
the country examining this phenomenon among Furthermore, social network use may influence
Filipino young adults, especially the user’s subjective well-being as more frequent use was
perceived personal benefits and risks. found to be related to experiencing a more
negative affect and reducing life satisfaction. (3)
For the fourth time straight, Filipinos were Experimental studies (6,7) have shown as well
declared the most active users on social media, that a break from Facebook improves subjective
according to the 2019 8th Global Digital Report well-being suggesting a causality in social media
(1), a compilation of social media trends use and poorer mental health outcomes.
representing 239 countries. Globally, 45% (3.49 Purported as well in studies is the addictive
billion) of the world’s total population are on nature of social media (8), yet research and
social media representing a 9% growth of users investigation on this is relatively new and many
from 2018. In the Philippines, time spent online questions still have to be answered. (4) Other
daily soared from 9 hours and 29 minutes in views also purport that social networking sites
2018 to 10 hours and 2 minutes every day on the may also protect from mental illness by
internet using any device (2), which is the supporting and enabling social interaction and
highest worldwide. The Philippines is also at the connection. (5)
top on social media penetration with 99% of the
internet users using at least one type of social The Facebook engagement of young adults has
media platform. For Filipinos, 4 hours and 12 raised considerable concerns among clinicians
minutes is the average daily time on social and researchers, especially of its consequences
media while the remaining hours is used video on productivity and subjective well-being.
streaming and listening to music. From 2018, Currently, there is still insufficient research
there has been a 13% increase in social media examining this among Filipino young adults,
users with 71% of the Philippine population representing a significant gap as Filipinos are
online. All over the country, Facebook remains to major users of social media.
be the most used social media platform with 97%
of the internet users using Facebook followed by Qualitative methods are suitable in developing
YouTube, FB messenger, Instagram and Twitter. concepts that help us understand social
Of the 76 million Filipino social media users, 75 phenomena in natural settings because it
million are on Facebook. For mobile phone emphasizes the individual meaning, experiences
social media use, 67% of online Filipinos access and views of the participants. (9) In this light, the
social media on their phone, maintaining social objective of the current research was to explore
media as an influential and a convenient force. Filipino young adult university students’
33% of the internet users are from the ages 18-24 engagement on Facebook and its perceived
years old followed by 30% from 25-34 years old. effect. And to better understand this
phenomenon, a qualitative study was conducted
Given that millions of Filipinos, especially young among young adult university students.
adults, invest hours daily on social media means
social needs are being met, but the type of REVIEW OF LITERATURE
impact it has on the user remains speculative. A
rise in quantitative social media research and Social Media Use in the Philippines
mental health has been noteworthy and there
have been numerous studies internationally Social networking is the most popular online
citing that online social networking may be activity among Filipino Internet users, with 95%
associated with several psychiatric disorders, accessing online social networking sites. (10)
including depression (3), anxiety and low self- Across ages, online activity is significantly higher
esteem. (4) A systematic review on social media among those aged 18 to 34 years old. Social
and mental health (5) added that prominent risk media uses "natural connections between people

23 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

to fill the connectivity gap created by dispersed depression are almost 11 times higher among
populations who no longer share geography but those with social media disorder using linear
still maintain relationships, such as families and regression analyses. (15)
friends". (11) Despite the country being an
archipelago, Filipinos are known to have strong In a quantitative study among 401 Malaysian
kin-based relationships hence it is no surprise adolescents with ages 13-16 years old in 2014
that the Philippines is reported to have the most revealed that activities centered on
Facebook users. (11) Mckay determined that communication such as being in touch with
Filipino Facebook users' “friends list” included friends revealed a positive effect on their
parents, children, uncles, aunts and extended psychological well-being. (16) Organizing events
senior or junior kin, including offline friends’ on Facebook such as arranging meet-ups and
parents, many living outside the Philippines. (12) gatherings also garnered a positive effect on
Filipino Facebook profiles are directed towards psychological well-being while seeking
extended family and long-distance connections, information on Facebook such as scrolling had a
interacting with multi-age groups connected by negative effect on psychological well-being.
kinship. Hence, families with family members Another study extended this work using
working overseas are twice more likely to use experimental and field methods demonstrated
the internet. (11) that passive Facebook use leads to decreases in
affective well-being and an identified
Social networking use and Well-being maintaining factor is in its enhancement of envy.
(17)
Studies on social network use have focused on
well-being and it would seem rightly so as the Another construct identified as a well-
World Health Organization has described established correlate of depression and social
mental health as “a state of well-being in which anxiety is self-esteem (18), consistent with clinical
every individual realizes his or her own models such as Beck’s cognitive model of
potential, can cope with the normal stresses of depression that emphasize negative perceptions
life, can work productively and fruitfully, and is in the emergence of mood and anxiety
able to make a contribution to his or her disorders. Hence, in accordance to Beck’s
community.” An emphasis on the factors that cognitive model, any damage to self-esteem may
affect well-being then would be necessary for increase the vulnerability to depression which is
awareness and prevention of mental illness. It is amplified in social media. (18)
an umbrella concept covering cognitive and
affective aspects of the evaluation of one’s life Factors that Influence Social Media Use
and measured by several indicators, such as life The Technology Acceptance Model by Davis (19)
satisfaction, affect, depression, or stress. (13) is a widely-accepted theory on the factors
affecting actual usage of a new technology.
Various authors have described social media use Davis initially described two constructs
as either beneficial or harmful. When harmful, it perceived usefulness (PU) and perceived ease of
is usually described as excessive use to the point use (EU) to explain computer usage behavior. He
of affecting the user’s work productivity and described that perceived usefulness is the
health. (14) A two-part quantitative study on 260 degree, to which a person believes that using a
young adults and 260 elderly participants (8) particular system would improve job
ascertained that the rise of social media has performance while ease of use is the degree, to
brought forth a form of social anxiety caused by which a person believes that using a particular
the concern of not being in touch with events system would be effortless. PU and EU then
named Fear of Missing Out (FoMo), concluding influences the attitudes of the individual towards
that fear of missing out is significantly predictive technology (intention). The intention to use
of social media use and problematic Internet use. technology will determine whether a person will
A quantitative, cross-sectional study concluded use technology or not (behavior). In this way,
that among senior high school students in the social media use may be influenced by the user’s
Philippines, the prevalence of depression was at perception of its purpose and ease of use.
73% with 86% of the respondents having a social
media disorder based on the Social Media Scale, Another model, the Uses and Gratification
concluding that the chances of having Theory explains the reasons people decide to

24 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

use a specific platform in a specific time and for This biased information may then produce
a specific situation. It proposes that humans have adverse effects when an individual compares
needs and these needs propel the user to gratify himself/herself with others online, impacting the
or reduce those needs using social media. In self-esteem. People may ask themselves
social media, cognitive related needs are questions like “Why am I still working at this
achieved using posting of difficult homework boring job, while my friends are seeing the
questions on sites, social needs are met though world?" Thus, Facebook users who engage in
connecting with family and friends and social comparison may feel that they are worth
emotional needs are met by maintaining social less than others and thus feel worse than others
ties with friends. (20) when they think that their own lives don’t meet
the seemingly happier lives of their Facebook
Furthermore, human beings are social beings friends. (22)
and constantly socialize through affiliating with
others. Abraham Maslow’s Theory of Basic In the present study, the students’ Facebook
Human Needs has noted that once the experience was categorized into purpose, ease,
physiological and physical needs are met, the content and type of use, which motivated them to
next level is the need to belong or affiliate. use Facebook more or less.
Through our interaction with others, we develop
a sense of ourselves including our self- Objectives
perception, self-esteem, and self-confidence. In The general objective of this study was to
adolescents, relationships with peers have shown explore the nature and extent of a young adult
to be related to self-perceptions and self-esteem, university student’s engagement with Facebook
as friends mutually validate each other’s self- and their perceived effects. Specifically, this
worth. (18) study aimed to explore the average time spent
on Facebook and its perceived personal effects
Festinger was the first to theorize that among young adult university students.
comparing oneself to others is a human need
essential for acquiring information about METHODOLOGY
ourselves. (21) A qualitative study design was used among
young adult university students enrolled in the
Denti et al. therefore, hypothesized that it may school year 2019-2020 with ages 18 years old
be that other people are mirrors to whom and above. Permission to conduct research was
individuals continuously reflect themselves to determined via a letter of request to the deans of
inquire information about others to answer the colleges after approval by the institution
questions on their identity. (22) And to address review board. Nineteen young adults were
these questions, they need information about recruited to participate in in-depth interview
others, of their actions, likes, and dislikes. described as a personal interview on their
Offline, this event may happen as well, but a Facebook experience with respect to thematic
study has shown that women rarely compare saturation.
themselves to women in billboards and
magazines and only sometimes compare In-depth interview was used for the purpose of
themselves to others on TV. (23) It is only in data collection due to the possible sensitivity of
social media that women are supposedly the questions and to decrease self-consciousness.
“normal” and accessible rather than intentionally The interviews allowed flexibility, allowing the
beautified models and actresses. (23) In our researcher to produce richer data and possibly
modern society, Facebook has offered an arena uncover issues on Facebook that have not been
where this event may happen. Using the anticipated by the researcher. (9)
information from Facebook, individuals
subsequently assess where he/she stands on a The Inclusion criteria were as follows: regular
continuum of skills, abilities, and so forth in a enrolled university students over 18 years old
process called Social Comparison. (21) However, who were registered Facebook users who logged
this process may be skewed in social media as in and visited Facebook through the website or a
people online often present a favorable mobile device in the last 30 days, who were able
description of themselves more than reality. (22) to independently access the internet and gave

25 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

consent for the study. The principal investigator, a psychiatry resident,
conducted the interview and each interview
The method of recruitment involving maximum lasted approximately 25-45 minutes at
variation purposive sampling occurred in two Psychiatry Outpatient Department to ensure a
ways. Recruitment was done primarily by the quiet and conducive interview. A nearby
principal investigator and every effort was psychiatric nursing staff was available in case of
made to ensure that the colleges, year level, ages, any discomfort from the respondent. The
and gender were well represented in the present interview dealt with several main themes; (a)
study. The first was through a Facebook participants’ general use and impression of
advertisement using the Facebook page of the Facebook, and (b) participants’ thoughts and
Psychiatry Department. Second, recruitment experiences with Facebook. Each interview was
advertisements via posters in the university and recorded with the use of a recording device and
guidance offices were done. Permission was the discussion subsequently transcribed.
obtained from the department and college Rigorous and thorough transcription including a
administrators before posting the verbatim account of utterances was done with
advertisements. The recruitment advertisement the help of the department research assistant.
informed students that the principal investigator The participants were provided a simple snack
was looking for interested college students over after the interview.
18 years who are willing to talk about their
Facebook experience in a personal interview for Recruitment of interviewees continued until
a research study. Furthermore, the thematic saturation was reached at 19
advertisement included the name and contact respondents, that is, when there was enough
details of the principal investigator. Every effort information to replicate the study, when the
was made to ensure that no aspect of the ability to obtain additional new information has
advertising materials was considered coercive been attained, and when further coding was no
or misleading. longer feasible. (24) There was 1 respondent
who was removed as he/ she did not meet the
The interested participant was asked to contact criteria.
the principal investigator through text or email
and was responded to as soon as possible. They Statistical Analysis
were e-mailed an abridged information sheet,
inclusion criteria and their responsibilities as Descriptive statistics was used to summarize the
participants. The information sheet also general and clinical characteristics of the
emphasized that participation is completely participants. Frequency and proportion were
voluntary. If the interested participants met the used for nominal variables, median and range
inclusion criteria as determined by the principal for ordinal variables, and mean and standard
investigator, he/she was asked to proceed to the deviation for interval/ratio variables.
Psychiatry Outpatient Department on their
preferred available time from 8:00 in the All valid data was included in the analysis.
morning to 4:00 in the afternoon, Monday to Missing variables was neither replaced nor
Friday. Once at the office, they were met by the estimated. Null hypothesis was rejected at 0.05α-
principal investigator who provided them with a level of significance. STATA 15.0 was used for
description of the study objectives and were data analysis.
asked to read the full study information sheet.
Any questions they had at the moment were Measures
answered to the best of the principal Sociodemographic Questionnaire: This was a 1-
investigator’s knowledge with the intention of not page questionnaire consisting of socio-
being coercive or misleading. Upon agreement demographic information. This will include
to participate, they were asked to sign an questions on age, gender, religion, living
informed consent indicating they wished to situation, relationship status, college course, year
participate in the current study, including level and family collective monthly income.
consent to be interviewed with subsequent
recording of the interview. The participant was Semi-structured interview: The semi-structured
then asked to complete a brief socio- interview was based on a flexible topic guide
demographic questionnaire. which provided open-ended questions to explore

26 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

experiences and attitudes of the students. The Around one third (36.84%) were second year
questions were loosely based on Burnette et al.’s students. Two (10.53%) students had previous
semi-structured interview schedule, which was psychiatric consultation and psychiatric
used in their study on the impact of social media medication intake. (Table 1)
and body satisfaction among female adolescents
using a focus group discussion. (25) Further
questions explore general Facebook use, peer’s
Table 1. Demographic profile of students (N=19)
posts and emotions/perceptions on social media.
Probing questions were asked when necessary.
Furthermore, the semi-structured interview
questions underwent face validation by two
consultant psychiatrists and a clinical
psychologist.

Methodological Considerations

Purposive sampling is advantageous in that bias

is reduced because the sample is constantly
refined to meet the study aims. (26) An attempt
to minimize participant bias was done by
continuing to recruit new participants into the
study during data analysis until data saturation
was reached. This current study was based on
assumptions that respondents had given honest
data and shared information on their use of
Facebook in an open and forthright manner.
Furthermore, to minimize participant bias, the
participants were ensured of the confidentiality
of the interview and the presentation of study
objectives were done in a non-judgmental
manner. An overly detailed description of the
study was avoided so as not to prime the
participants. Data collection bias was overcome
with the use of a semi-structured interview to
ensure flexibility during the interview, allowing
exploration of spontaneous issues raised by the
interviewee. The wording of questions was also
flexible to facilitate different levels of the English
and Filipino language to be used. Confirmation
bias was minimized by asking the help of an
objective researcher to code the data and by
verifying the results with literature.

RESULTS
A total of 19 students were included in the study
with a median age of 20 years old (ranges from
19 – 26 years). Most of the respondents were
female (63.16%), single (73.68%), heterosexual
(73.68%) and Roman Catholic (57.89%). Many
lived with their family (42.11%) or with
Participants had a median number of 4 social
roommates (42.11%). A third (36.84%) had a
network accounts with a range of 1-7 accounts;
collective family income of around 50,000 to
and their mean social media use over the course
100,000 pesos/month; while a fourth (26.32%)
of their life was 9.56 ± 1.82years or about half
were from the College of Medicine and another
their life.
one fourth (26.32%) from the College of Nursing.

27 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

Facebook was the most used social media communicating but for entertainment as well.
platform with a median score of 5, followed by Entertainment on Facebook was characterized
Instagram with a median score of 4. Cellphone as memes, inspirational material such as
was the most used device to access social media motivational quotes and Bible verses, and
sites, having a median score of 5. (Table 2) accessibility of information about society
through the news.
Table 2. Social media use of students (n=19)
When asked about their positive experiences on
social media, a female respondent replied, “I get
to connect with people that aren’t proximal to me
- my relatives that are abroad, I get to see their
pictures of whatever celebrations or event they
had, and my friends na matagal ko nang hindi
na-meet.” A male student replied, “You can use
the platform, the application to encourage other
people and to lift their spirits and I think that’s a
very nice thing about Facebook”.

Another theme that emerged was the increasing

academic activities on Facebook. The students
noted that their time on Facebook increased
because of Facebook groups shared with
classmates and professors where they exchange
information about school e.g. homework,
lectures and PowerPoint presentations. Indeed,
the students agreed that Facebook use has also
become an academic platform for them as a
Students preferred to use social media for female student described “Mas convenient na
entertainment and leisure (94.74%), social siya kung compared na kung kailan na talaga
networking (73.68%), and information seeking mag meet up yung class dun parang makaka
(57.89%). (Table 3) access ka na ng mga info kahit yun lang, kahit
naka upo ka lang”.
Table 3. Social media use of students (N=19)
Furthermore, the students noted that positive
social comparison also took place on Facebook.
This included seeing close friends who had
attained success, which then inspired them to be
able to do the same. In positive social
comparison, the level of friendship was
important: the closer they were to a person, the
more positive the experience. When asked about
how she felt about her close friends’ posts, she
General Factors leading to a positive experience said, “When I see someone who's genuinely
on Facebook happy, then it feels like it's something to be
happy about . I become happy for them.” A male
Several themes emerged regarding factors that student further described having witnessed a
led to a positive experience on Facebook. Some friend’s success personally as pleasant, “… Like
of the students stated that the content on my friend was working really really hard on a
Facebook played an important role on why they project tapos nasundan ko yung path niya to the
continued using the platform. Specifically, project. … I feel very very happy for them.”
keeping in touch was one theme characterized
as the ease of communicating with family and The students were asked on celebrities as it was
friends abroad and locally, and another theme thought that self-comparison would be greater
was that Facebook was not just for with the students, yet the students mentioned that

28 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

posts by celebrities do not make much of an popromote, or pasado na sa boards, ako nandito
impact as they take into account situational pa rin kaya minsan pag may nakikita ako ng
differences. “Friends have more impact because ganun, nag sastop na ako mag Facebook.”
you interact with them in real life,” according to
a female respondent. The students also noted that there was a feeling
of guilt most especially when they have been on
On Facebook, most of the students mentioned the platform longer than they had initially
that they rarely posted about themselves, except intended. Specifically, the students described the
for special events in their lives such as guilt as being less productive with their
commemorating victories and milestones. academics because of the time they spent on
Emotions of happiness were felt when their posts social media. One potential reason they
get noticed and appreciated by the number of mentioned was the increasing academic activity
likes. Most especially, receiving comments would on Facebook, which made them stay on the
increase their positive feelings as commenting platform longer and thus allowed them to see
involves more effort. Being remembered by notifications that distracted them from their
friends and seeing old photos of themselves academic purpose and resulting in prolonged
remind them of how far they have come was time spent online.
perceived to improve their self-esteem.
Another significant theme that emerged was the
General Factors that lead to a negative feeling of Fear of Missing Out as prolonging
experience on Facebook their use and increasing the guilt they felt as one
Themes that emerged in factors that led to a male student mentioned, “Yeah. I have tried
negative experience included negative content quitting Facebook. But yung problem ko now is if
on Facebook (FB) such as fake news, Facebook I tried to regulate it, there might be certain news
friends who give negative vibes by posting rude or updates from school na, that I might miss.”
content and friends with conflicting values and
opposing views on politics and gender. A male Aware that they tended to spend more time on
respondent answered, “Siguro ‘pag nakikita ko Facebook, some of the students have refrained
things that are against my principles … e.g. from using it to focus on academics and detoxify
politics, discrimination.” or tune out unnecessary inputs from Facebook
as one student said, “Minsan instead na
The students also mentioned previous nakakarelax, may times minsan … ang toxic ang
experiences that caused them not to post on daming opinon nag caclash…”
Facebook anymore such as being mocked for
their beliefs and witnessing their friends being But they admit to still eventually using FB
bullied for what they posted. Because of this, because they fear missing out on updates from
they have utilized other social media platforms friends, family, school and society. Another
for these specific purposes. Due to negative factor increasing the negative experience was
experiences, some students unfriended those the need to see something to make them feel
people to lessen the negative environment on good, attaining it and then wanting more of it,
Facebook. further prolonging time on Facebook despite
their heightened feeling of guilt. One male
Another theme included Negative Social respondent described the feeling as “I’m trying
Comparison that also occurred on Facebook to look for that final shot na, that final post na
when the students saw other people and highest dopamine but it’s always that small
perceived them as having more time and amount. But it (the post) never comes, it’s always
resources than they had at that time. These that small amount and when I reach that big
experiences made them feel envious and sad, post, I’d say, sige one more.”
which they perceived to affect their self-esteem.
Not surprisingly, the students mentioned that Significantly among the students, they denied
these experiences often caused them to feel experiences of cyberbullying, but some admitted
worse than when they started after using to witnessing Facebook friends being bullied.
Facebook such as when a male respondent said,
“Yung sa mga accomplishments, na ooverwhelm
ako, sabi ko “sila may mga jobs, may ganito, na

29 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

Difference between the Students’ Perception on Another theme that emerged was on limiting the
Social Comparison number of hours on Facebook. Specifically, that
it must be defined by how they use Facebook
Interestingly, majority of the students were quick especially if academic materials are available
to point out that negative social comparison was online. If used for entertainment, they suggested
more serious when they were younger, when on average, 1.7 hours or 101 minutes on Facebook
they were in grade school and high school. They daily. If with academic use, they suggested 3.8
described it as a time where they were hours or 230 minutes. Lastly, a theme that
competitive for likes and posted as much as they emerged was on curating their own feed by
can to get likes to feel good about enough about removing toxic content and creating an
themselves. A common theme among the environment that do not make them feel worse
students’ answers on what the change was, or than when they started using.
what made their reaction less intense than
before was that they have become aware that DISCUSSION
not all things on social media was true.
Furthermore, they also ascribee it to having Today, Facebook has offered a wide arena
matured, that they are not the same user that where students are exposed to opportunities to
they were when they were younger such as when connect and exchange information about
a female respondent said, “I think during themselves, their families and society. For some
puberty there is this hyper-self-consciousness of students, this engagement with Facebook may
how everyone looks at them and social media also result in over-involvement. In the study, the
amplifies that and puts you in a page where students’ average time on social media was 4
everything is about you and people look at you”. hours and 30 minutes, which is comparable to
Another male respondent said that, “Through the national finding of 4 hours and 12 minutes.
time, parang na-realize ko na parang hindi On Facebook, specifically, the average time
naman talaga yun yung totoong world, ang spent daily was 2.9 hours or 176 minutes which
social media. Kasi, ‘Ano man kung may mag like means 1/8th of their day is spent on Facebook
or wala, ano man kung ano iniisip nila sa akin.” which may affect productivity, but it is also
important to consider that most of the students
Students’ Recommendation on Facebook Use felt forced to be online due to academic reasons.

Knowing the impact of their Facebook use on The results of the present study may have
their productivity and on themselves previously important implications for the Facebook
and currently, majority of the students have experience of young adults. First, several
recommended some strategies on Facebook use. students reported feeling positive and negative
A common theme that emerged on the use of emotions when encountering posts by Facebook
Facebook was that awareness was critical. friends. Specifically, in the study, the level of
Specifically, awareness that posts have been friendship was important. Commemoration posts
curated and edited to become appealing and by close friends and family members elicited
that not everything online is really as it is. more positive emotions such as shared
Another theme that emerged was that parents happiness and provide inspiration, while
should take an active role especially for high celebrities whom they had no relationship with
school students who use Facebook for academics elicit more of a neutral feeling. This was in
as well. Teenagers’ Facebook use must be keeping with previous research, which revealed
regulated by their parents and the family should that positive news by a strong tie (close friend)
be involved in the initial opening of a teenager’s was more likely to elicit happiness and benign
FB account. Some of the students acknowledged envy, a type of envy that motivates one to
that Facebook use is now part of social improve. (27) The mechanism purported for this
development so students cannot be prevented type of response is the phenomenon of
from using it. “I don’t want to stop my child from Emotional Contagion, which is described as “the
using it because I feel like it’s part of their tendency to automatically mimic and
development. It cannot be separated anymore at synchronize expressions, vocalizations, postures,
this age. You just have to regulate it. Even the and movements with those of another person’s,
ability to just use a tablet, if they can’t use that, and consequently, to converge emotionally”. (28)
then they are so behind”. Emotional contagion is stronger when the

30 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

individuals are closer and is also true when a prior to Facebook. Eighty two percent (82%) of
sad post from a close friend elicits sadness. them reported having at least one negative
Facebook experience since they started and 24%
However, there were also students who reported reported moderate to severe levels of depressive
negative emotions of jealousy and sadness when symptoms on the Center for Epidemiological
they encountered negative social comparison on Studies Depression Scale, concluding that the
Facebook. Frequent bombardment of reminders overall risk for depressive symptoms was 3.2
of what one “should be and do” may make the times greater than those who did not have
student feel sadder. When all one sees on social negative experiences. Interestingly the study
media are everyone’s best and brightest, found that severity of upset was greater in
comparing oneself is expected to affect one’s Facebook negative experiences in adolescents
view of the self. (29) than in young adulthood. (30)

Envy may arise from a phenomenon called Physiologically, adolescents are at a higher risk
Upward Social Comparison, which is described than young adults because of their
as comparing oneself with better-off others, most underdeveloped prefrontal cortex that forms
especially in domains important to self- judgments and controls impulse and emotions.
definition. (27) An example of this in the present With adolescents, there is a heightened need for
study was when students compared themselves reward but an underdeveloped control system,
with better-off others who had married or had a prefrontal cortex, hence possible negative
stable job while they were still studying. Lin & outcomes are outweighed by the potential thrill
Utz concluded that relationship closeness did not they receive with validation on social media.
play a role in the feeling of envy but more likely Adolescents also turn to peers more than family
predicted by individual characteristics of the to seek validation. So, an underdeveloped brain
user such as low self-esteem. (27) seeking validation sees glamorous social media
posts laying the foundation for loss of
Furthermore, the young adults in the present confidence, depressive symptoms, and harm.
study mentioned that their present Facebook (31)
experience was different when they were
younger as they were more susceptible to social Furthermore, adolescents who spent more than 3
media’s influence. Having said that, Facebook hours a day on Facebook were at increased risk
may be framed as a risk for the self, due to its for depression or anxiety because they were
accessibility and especially among vulnerable more likely to internalize problems, which may
population, such as adolescents. be explained by sleep problems and
cyberbullying. (32)
Negative experiences online also included
negative encounters with friends and even the On the other hand, Orth & Robins and Bleidorn
general tone of the news feed. Students have et al. agreed that from adolescence to early
reported that seeing conflicting sociopolitical adulthood, self-esteem became progressively
views and opposing values on their feed were less contingent or dependent on the external
distressing, often causing them to unfriend or such as experiences of success and failure.
mute a person online. Seeing a friend post about Young adults increasingly engage in
their beliefs online and witnessing that friend instrumental and social roles and become even
persecuted also elicited fear, should they do the more independent from their family. This
same thing. mastery and the socioemotional feedback they
get from themselves convey a sense of self-worth
A study among young adults exposed to at least and lead to increases in self-esteem. (33, 34)
one negative experience on Facebook – bullying,
meanness, misunderstanding or unwanted Hence, it is prudent to recognize that these
contacts – was noted to significantly increase negative experiences on Facebook could lead to
their risk for depression, despite accounting for symptoms of depression and it might be
many possible confounding factors. The 264 worthwhile to take a break. And as the students
young adults were also previously enrolled as recommended, to unfriend these people and
adolescents in the New England Family Study, clean up their news feed.
where the researchers knew how they were

31 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

Yet drawing on the Uses and Gratifications ones, it has increasingly become an arena where
(UGT) theory, we can also infer that Facebook students encounter positive and negative
also offers features that provide positive experiences. While the study did not determine
gratifications such as the need to connect, the which was more dominantly experienced, the
need to belong, and the need for self- results of the study revealed that positive
presentation. Facebook has also become an experiences were related to the level of closeness
academic platform where Facebook groups of relationship. Also, negative experiences on
have become essential in exchanging academic Facebook were mostly due to negative
information. In a qualitative study among encounters with friends and the general tone of
professors in the United Kingdom, Facebook was the feed, which are increasingly about
viewed as beneficial in increasing student sociopolitical issues. Furthermore, the study
engagement in classroom discussions outside the explored the experiential change from
classroom however, they cited the importance adolescent to young adulthood in how they
for both the staff and students to be conscious perceived their Facebook experience.
and adhere to professional standards online.
(35) Hence, using Facebook for academics Limitations
should be used by the student administration as
an opportunity to provide guidance and discuss The present study was a qualitative study and
online professionalism and behavior to the the findings must still be considered in light of
students and staff. some important limitations. First, the themes
were saturated among young adult university
Facebook, as a social media platform, is students and so, it might not apply to different
multifaceted and cannot be conceptualized just ages and culture. Second, the data was limited
by the time spent on it. In the same way that and only documented what the respondents
Facebook use is also a double-edged sword, were willing to share at that specific point in
where young adults present their best and time, which may also have been limited by how
brightest and let others attribute value to them in the researcher established rapport.
terms of likes and comments, which has its
consequences. (36) Awareness is critical and Recommendations
parents need to take an active role in their
children’s social media use. In the same way that Based on the limitations, it is suggested that
parents have “the talk” on sex, alcohol, and future studies explore adolescent and young
drugs, perhaps in our present time, social media adult social media use along with other social
could now be a part of the talk rather than media platforms such as Instagram and Twitter.
preventing them from using it. (37)

Another finding in the study is that Fear of

Missing Out occurs among the students, which is
an actual social anxiety that you are missing an
event or opportunity, which Reyes described as
predictive of problematic internet use, keeping
students hooked on Facebook. (8) It was found in
the present study that academic engagement
kept them purposely on Facebook but also
enticed them to take more time using it. In this
light, it would be prudent to explore the
academic engagement of the students on
Facebook and quite possibly explore the use of
other platforms, as well.

Conclusion

Social media has drastically shaped the way, in

which people engage with the world and have
become the new reality we face. While it is a
great platform to stay connected with loved

32 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

REFERENCES
19. Davis FD. Perceived usefulness, perceived ease of use, and user
1. Kemp S. Digital in 2019: Global Internet Use Accelerates.
acceptance of information technology. MIS Quarterly. 1989 Sep;
Available from: https://wearesocial.com/uk/blog/2019/01/digital-
13(3): 319-340. Available from: jstor.org/stable/249008.
in-2019-global-internet-use-accelerates/
20. Katz E. Mass communication research and the study of popular
2. Gonzales G. Filipinos spend most time online, on social media
culture: an editorial note on a possible future for this journal. Studies
worldwide – report. Rappler [Internet]. 13 Jan 2019 [cited 2019
in Public Communication. 1959; 2: 1–6. Available from:
August 5] Available from:
https://repository.upenn.edu/asc_papers/165.
https://www.rappler.com/technology/news/222407-philippines-
21. Festinger L. A Theory of Social Comparison Processes. Human
online-use-2019-hootsuite-we-are-social-report
Relations. 1954; 7(2): 117-140. doi:10.1177/001872675400700202
3. Kross E, Verduyn P, Demiralp E, Lee DS, Lin N, Shablack H, et al.
22. Denti L, Barbopoulus I, Nilsson I, Holmberg L, Thulin M,
Facebook Use Predicts Declines in Subjective Well-Being in Young
Wendeblad M, et al. (2012). Sweden’s largest Facebook study.
Adults. PLOS ONE [Internet]. 2013 [cited 2019 August 5;
ResearchGate [Internet]. 2012 [cited 2019 September 10]. Available
8(8):e69841. doi: 10.1371/journal.pone.0069841. Available from:
from:
https://journals.plos.org/plosone/article?
https://www.researchgate.net/publication/254419705_Sweden’s_larg
id=10.1371/journal.pone.0069841
est_Face book_study
4. Pantic I. Online Social Networking and Mental Health.
23. Fardouly J, Pinkus RT, Vartanian LR. The impact of appearance
Cyberpsychology, Behavior, and Social Networking. 2014; 17(10):
comparisons made through social media, traditional media, and in
652-657. doi:10.1089/cyber.2014.0070
person in women’s everyday lives. Body Image. 2017; 20: 31-39.
5. Seabrook EM, Kern ML, Rickard NS. Social Networking Sites,
doi:10.1016/j.bodyim.2016.11.002
Depression, and Anxiety: A Systematic Review. JMIR Mental
24. Fusch PI, Ness LR. Are we there yet? Data saturation in qualitative
Health. 2016; 3(4):e50. doi:10.2196/mental.5842 PMID:
research. The Qualitative Report. 2015; 20(9): 1408-1416. Available
27881357PMCID: 5143470
from: http://www.nova.edu/ssss/QR/QR20/9/fusch1.pdf
6. Vanman, EJ, Baker R, Tobin S. The Burden of Online Friends: The
25. Burnette CB, Kwitowski MA, Mazzeo SE. “I don’t need people to
Effects of Giving Up Facebook on Stress and Well-Being
tell me I’m pretty on social media”: A qualitative study of social
[Internet]. 2018 [cited 2019 August 20]. Available from:
media and body image in early adolescent girls. Body Image. 2017; 23:
https://psyarxiv.com/8vwf6/ doi:10.31234/osf.io/8vwf6
114-125. doi:10.1016/j.bodyim.2017.09.001
7. Tromholt M. The Facebook Experiment: Quitting Facebook Leads
26. Smith J, Noble H. Bias in research: Table 1. Evidence Based
to Higher Levels of Well-Being. Cyberpsychology, Behavior, and
Nursing. 2014;17(4):100-101. doi:10.1136/eb-2014-101946
Social Networking. 2016; 19(11):661-666.
27. Lin R, Utz S. The emotional responses of browsing Facebook:
doi:10.1089/cyber.2016.0259
Happiness, envy, and the role of tie strength. Computers in Human
8. Reyes ME, Marasigan JP, Gonzales HJ, Hernandez KL, Medios MA,
Behavior. 2015; 52: 29–38. doi: 10.1016/j.chb.2015.04.064
Cayubit RF. Fear of missing out and its link with social media and
28. Hatfield E, Cacioppo JT, Rapson RL. Emotional Contagion. Current
problematic internet use among Filipinos. North American
Directions in Psychological Science. 1993; 2(3):96-99. doi:
Journal of Psychology. 2018; 20 (3): 503-518. Available from:
10.1017/cbo9781139174138
https://www.researchgate.net/publication/329163251
29. Wagner J, Lüdtke O, Jonkmann K, Trautwein U. Cherish yourself:
9. Al-Busaidi ZQ. Qualitative research and its uses in health care.
Longitudinal patterns and conditions of self-esteem change in the
Sultan Qaboos University Medical Journal. 2008; 8 (1): 11-19.
transition to young adulthood. Journal of Personality and Social
PMID: 21654952; PMCID: PMC3087733. Available from:
Psychology. 2012; 104(1): 148–163. doi: 10.1037/a0029680
https://pubmed.ncbi.nlm.nih.gov/21654952/
30. Rosenthal SR, Buka SL, Marshall BD, Carey KB, Clark MA. Negative
10. Labucay ID. Patterns of Internet Usage in the Philippines. In J.D
Experiences on Facebook and Depressive Symptoms Among Young
James (Ed.), The Internet and the Google age: Prospects and
Adults. Journal of Adolescent Health. 2016; 59(5): 510–516. doi:
perils (pp. 27-49). 2014. Dublin: Research-publishing.net. doi:
10.1016/j.jadohealth.2016.06.023
10.14705/rpnet.2014.000176
31. Santrock J. Lifespan development cnct. North Ryde (NSW):
11. Fontamillas AE. Social capital and Facebook use of Tacloban city
Mcgraw-Hill Education; 2014.
after super typhoon Haiyan. Open Access Te Herenga Waka-
32. Riehm KE, Feder KA, Tormohlen KN, Crum RM, Young AS, Green
Victoria University of Wellington. Thesis.
KM, et al. Associations between time spent using social media and
https://doi.org/10.26686/wgtn.20387946.
internalizing and externalizing problems among US youth. JAMA
12. Mckay D. Historical images and personhood in Filipino social
Psychiatry [Internet]. 2019 [cited 2019 September 16]; 76(12):1266–
network. History and Anthropology. 2010 Dec; 21 (4): 479–498.
1273. Available from:
DOI:10.1080/02757206.2010.522311 Corpus ID: 143763917
https://jamanetwork.com/journals/jamapsychiatry/article-
13. Utz S, Breuer J. The Relationship Between Use of Social Network
abstract/2749480. doi:10.1001/jamapsychiatry.2019.2325
Sites, Online Social Support, and Well-Being. Journal of Media
33. Orth U, Robins RW. The Development of Self-Esteem. Current
Psychology. 2017; 29(3):115-125. doi:10.1027/1864-1105/a000222
Directions in Psychological Science. 2014; 23(5): 381–387. doi:
14. Olufadi Y. Social networking time use scale (SONTUS): A new
10.1177/0963721414547414
instrument for measuring the time spent on the social networking
34.Bleidorn W, Arslan RC, Denissen JJA, Rentfrow PJ, Gebauer JE,
sites. Telematics and Informatics. 2016; 33(2): 452-471.
Potter J, et al. Age and gender differences in self-esteem—A cross-
doi:10.1016/j.tele.2015.11.002
cultural window. Journal of Personality and Social Psychology. 2016;
15. Siongco P, Rosales V. Social media disorder and depression
111(3): 396–410. doi: 10.1037/pspp0000078
among Filipino adolescents: A cross-sectional study.
35. Prescott J, Stodart M, Becket G, Wilson S. The Experience of using
[Unpublished research]. [Manila (PH)]. University of Santo Tomas;
Facebook as an Educational Tool. Health and Social Care Education.
2018 [cited 2019 June 9]
2013. doi: 10.11120/hsce.2013.00033
16. Sommyyeh N, Tamam E, Hassan S, Bolong J. Facebook usage and
36. Parnell B. Is Social Media Hurting Your Mental Health? [Internet].
its association with psychological well-being among Malaysian
Toronto, Canada: TedxRyerson University; 2017, June 23 [cited 2019
adolescents. Procedia – Social and Behavioral Sciences. 2014 Nov
September 10] Available from: https://www.youtube.com/watch?
6; 155: 87-91. doi:10.1016/j.sbspro.2014.10.261.
v=Czg_9C7gw0o
17. Verduyn P, Lee D, Park J, Shablack H, Orvell A, Bayer J, et al.
37. Parnell B. #SafeSocial: Social Media as a Risky Behaviour. Medium
Passive Facebook usage undermines affective well-being:
[Internet]. 2019 February 7 [2019 October 10]. Available from:
Experimental and longitudinal evidence. Journal of Experimental
https://medium.com/p/2e4f8782f14d
Psychology Gen. 2015 Apr;144 (2): 480-488. doi:
10.1037/xge0000057. Epub 2015 Feb 23. PMID: 25706656.
18. Bosacki S, Dane A, Marini Z, Ylc‐Cura. Peer relationships and
internalizing problems in adolescents: Mediating role of self‐
esteem. Emotional and Behavioural Difficulties. 2007; 12(4): 261-
282. doi:10.1080/13632750701664293

33 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

 PJP CASE REPORT

TYING IT ALL TOGETHER:

CASE OF AUTISM SPECTRUM DISORDER WITH PARAPHILIC ACTIVITIES

MELANIE TONGOL, MD
THE MEDICAL CITY
DEPARTMENT OF PSYCHIATRY

ABSTRACT

Autism Spectrum Disorder (ASD) is a phenotypically heterogenous group of

neurodevelopmental syndromes characterized by a wide range of impairments in social
communication and restricted and repetitive behaviors. (1) The majority of individuals
with ASD go through puberty and experience the same physical and psychosexual aspects
of sexual development as their peers. However, there are notable problems with regards
to sexuality especially at the start of puberty when the development of social skills
cannot keep up with the increasing social demands, and the difficulties of forming
romantic and sexual relationships become evident. (2)

The case presented here is a 26-year-old male with a history of engaging in paraphilic
activities that showed the complexities of ASD (Asperger Syndrome) in their sexual
behavior.

CASE PRESENTATION He shared his long-term fantasies of tying up a

girl and subjecting her to pain, humiliation and
Chief Complaint sexual stimulation, which was never realized
Jay was a 26-year-old Filipino male, Christian, given his Christian belief that it was wrong.
single, seeking consult for intrusive thoughts with
themes of bondage & discipline, dominance After meeting someone who shared his hidden
&amp; submission and sadism &amp; desires, he was able to muster the strength to live
masochism (BDSM). out his fantasies and met with the said chatmate.
They planned their BDSM roles and restrictions,
History of Present Illness with Jay as the dominant and the chatmate as
Jay described himself as curious, ambitious, and submissive. On the day of their meeting, Jay
peculiar. Despite trying to be sociable and packed ropes in his bag, as he remembered his
extroverted, he had difficulty connecting with past fascination with them when he was still a
friends and he often ended up alone. This has boy scout. he met his chatmate at the delivery
been a recurring experience since childhood. area of a mall and there began his string of
novel sexual pursuits. He started binding her
Five years prior to consult, Jay’s excitement was hands and legs behind her. Both lying on the
hyped, as a female chatmate opened up the floor, fully clothed, he kept on tying her as if he
topic of BDSM. was in a trance. Merely having his partner

34 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

helpless and subdued gave him maximal He was put off by the girl persistently initiating
pleasure more than the idea of penetrative sex. the role play. Later on, he found out that she
After an hour of bondage drama, he went home switched to the dominant role.
and finished off his carnal experience with
masturbation. Though devoid of physical In the interim, most of his energy was focused
attraction, he continued meeting his chatmate on his medical studies, quieting down in the
the entire year solely for the kink. One time, they BDSM scene as it might disrupt his daily routine,
were role playing in the public pool of his as he put it, “ruining the regularity of things.”
condominium when the window cleaner However, his fantasies were continually lived out
unexpectedly caught him tying his chatmate. Jay in his head outside the knowledge of anyone for
fear of being ostracized.
froze for a moment, but he was not deterred and
continued on. That whole afternoon he tied her
Two years prior to consult, when he met a 19-
in certain embarrassing patterns and difficult
year-old female chatmate in the BDSM website,
positions. Such role playing was made more
he found her alluring because she was
exciting with derogatory language, ordering the
outspoken and begged him to do the things they
partner to be quiet or calling her a slave.
were chatting about, which involved tying her
Excitement though would be short-lived as he
up and humiliating her. Like the previous
would later feel guilty engaging in these
women, they met to talk about the arrangement
unconventional practices. After their 4th
and to his liking, she agreed to stripping naked,
meeting, his chatmate decided to cut ties with
which was the first time someone agreed. On
him. She allegedly explained that it was because their scheduled roleplaying day, he pursued his
of his Christian convictions; however, this left Jay sexual desires, such as tying her arms behind
feeling puzzled with the irony of why this non- her back, giving her a cold shower, and leaving
religious girl was the one affected. her hanging on the balcony, drying her off
using the aircon radiator. Wanting to humiliate
In the interim, wanting to connect with other her further, he made her sleep naked on the
BDSM enthusiasts, he joined a local social floor, tying her later under the table. While she
networking site. As he became busy with school was on the floor, she started nibbling on his
being a graduating student, chatting with other genitals leading him to ejaculate on her body.
females online, watching BDSM porn and Even if there was no penetration, he felt guilty
reliving what transpired the previous year because his genitals were touched for the first
allowed him to satisfy his appetite for this kind time. Taking it to the next level of putting her
of sexual expression and forego physical role inside a luggage to roam around the city, the
play. Though he did not know whether he should plan was prematurely terminated, as he
feel guilty for indulging in these sexual remained frightened from the unexpected
perversions because he was a Christian, he arrival of the household help. Wracked with
carried on with this practice. He justified his guilt for going against his Christian beliefs, he
actions and the normalcy of such since there cut himself off from sex, masturbation and
were professionals, even physicians, in the local pornography. He then he joined the religious
scene who were actively engaging in BDSM. organization in school and led the monthly
Bible studies to clear his conscience.
Three years prior to consult, before he started
medical school, he invited his 25-year-old In the interim, he continued having cravings for
female chatmate to role play their fantasies. BDSM but tried to drown them out by keeping
They met over lunch to agree on their limits and busy with school. As the guilt ebbed away, he
again succumbed to pornography involving
safe words. In his condominium unit, when they
themes of violence, which gave him intense
began, he asked her to strip but she refused. He
sexual pleasure more than normal sex.
respected her decision and did not persuade her
Frequently immersed in sexual thoughts, he
since it was stipulated in their written agreement.
would masturbate even at inconvenient times.
There was a lot of immobilizing to the point of
Despite this, he continued sex chatting often
him almost wrestling with her- embracing and
tempted to hook up.
straddling her with no penetration involved.
After this, they talked a few more times before
Two months prior to consult, stress from the
the communication died down and eventually
increased school workload, transient thoughts of
stopped talking to each other.
violence or sex “popped up” more frequently.

35 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

Thoughts of groping his classmate’s breast or usually out of proportion to the situation.
angrily stabbing someone with a pencil would be Mistakes that are deemed minor for Jay already
present but dismissible. Though short-lived, the makes Julia scream in distress towards him.
increased frequency of such thoughts confused Since he started living on his own, their
him. He denied marked anxiety or distress over relationship has improved. She would often ask
the thoughts, adding it was not time-consuming, him to accompany her when going out as his
only lasting less than 30 seconds. There were no siblings were said to be busy with their own
attempts to ignore or suppress the thoughts with partners. Julia would often rant to him and
some other thought or action. He also reported confide her feelings about how Joseph does not
having no drive to perform repetitive behaviors take care of her or bring her out. Given her
or mental acts in response to the intrusive religious background, Julia always emphasized
thought. However, anticipating his incoming to her children that premarital sex is a sin. Jay
never got to ask topics related to sex and
medical clerkship, he feared that the stress may
intimacy as it was considered taboo in their
tip the balance to give in to what he wishes to
household.
dismiss hence leading him to seek consult.

Siblings
On psychiatric review of symptoms, Jay denied
depression, generalized anxiety, hypomania,
Carla, 24 years old, is Jay’s only sister. She is an
mania and psychosis. He endorsed guilt over
incoming 2nd year law student. She and Jay
sexual fantasies and his perceived inability to
used to fight a lot when they were little because
socialize like his peers.
she wouldn’t follow his instructions when they
played. According to Jay, he feels that their
Family History and Profile relationship has improved now that they’re
There were medical illnesses but no known older; although he still gets annoyed with her
psychiatric illnesses in the family. His paternal when she would get his belongings and claim it
grandfather had hypertension that led to a as hers.
stroke. His mother has hypothyroidism and his
sister has bronchial asthma. Ramon is 22 years old. Having been in and out
of college for 4 years now, he’s supposed to be
Parents graduating but was kicked out in his first school
due to low grades and absences. He now takes
His father, Joseph has his own business involving music production, which their parents did not
marine based transportation services. He was allow at first saying there was no money in it.
described to be rigid, headstrong and Jay feels responsible for his brother’s lack of
introverted but could socialize when needed. Jay motivation in school thinking it was because
shared that his father would rather not have to Ramon was compared to him by teachers in
do anything with people and this extended to the their grade school and high school.
family especially with Jay’s mother who would Sid is the youngest, aged 11 years old. When
complain about not getting affection from him. their parents are not around, Jay is given the
Growing up, Jay was scared of him as he responsibility to take care of him. Jay described
experienced corporal punishment- spanked, that among his siblings, he finds himself closest
pushed, shouted at and given derogatory to Sid, saying: “if closeness had a velocity, Sid
remarks. Now that he’s an adult, his father would would have the highest because ours is
still give snide comments. He admitted not increasing”.
looking forward to spending time with him as
there is ongoing tension between them. Jay tries to be a responsible “big brother” to his
younger brothers, Ramon and Sid.
Patient’s mother, Julia used to design cakes for
Developmental and Social History
weddings and now helps with her husband’s
Jay was an unexpected but wanted pregnancy
business. Jay has a close relationship with his
born via cesarean section due to cord coil to a
mother but admitted feeling confused with her
primigravid 22-year-old mother. His father was
inconsistent parenting—nice and sweet one
forced to marry his mother due to his
moment to agitated and distressed the next when
conservative and religious parents
things do not go her way. For Jay, her reaction is

36 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

At age 1, his mother left for Singapore to study household help’s feet. He described the feeling as
leaving him under the care of his father and having a balloon that’s pumping inside his chest.
maternal grandmother. At age 2, his mother Despite all his curiosities and what he was feeling
came back and she became his primary inside, he never got to ask his parents about it,
caregiver with the assistance of the household for fear of being berated.
help.
In grade school, he never understood his
During his toddler years, he became scared of classmates’ interest in the trendy games at the
his father as he would be spanked every time he time and instead immersed himself in Science
asked him to stop smoking, which Jay did upon books and school work. His classmates were
his mother’s instructions. never considered as friends, more of just
playmates. He did not exert effort to be friends
In the few occasions of story-based play with his with them and to be liked by other children his
sister, he would get annoyed when she never age. It was during this time that he was partial to
listened and followed the way he wanted the the number ‘3’—getting stuff in three’s and
story to unfold. She would leave him to clean up grouping his belongings by three’s. This was
and he would fix the stuffed toys in a certain observed by his mother who got annoyed
arrangement or pattern like by color or by because he bought groceries or school supplies
importance. in three’s.

In preschool, he would play with his classmates At age 8, his paternal grandfather occasionally
whom he considered as playmates. However, fondled his scrotum for a few seconds as a way
these playmates never invited him to play with of greeting him, which he thought was normal.
them or to attend their birthday parties. His Feeling uncomfortable, he told his mother about
other interactions with them outside the the multiple episodes he was touched but she did
playground was restricted to one- on- one play not react. The dismissal of what he was feeling
with videogames. made him sad as he expected her to protect him.
He was left to deal with it alone, mustering the
At age 6, diagnosed with chordoma, his family courage to tell him not to touch him after 2
became religious and converted to Born Again years. He denied nightmares, flashbacks,
Christian. The family believed that the success in avoidance, or hypervigilance. He never thought
his surgeries was because of God’s work. He of telling his father about it also because around
remembered staying in the United States for his the same time, his father preferred to go on
craniotomies and not understanding the nature drinking sprees with his friends rather than
of his diagnosis. During this ordeal, his parents spend time with his family. On the rare occasions
doted on him with his father calling him “best that his father was home, his father would be
buddy,” giving him a sense of pride. He liked it irritable and angry as well as physically and
when his mother held his hand during verbally abuse his mother. He remembered
procedures and brought him to tourist being angry at his father for inflicting pain to his
attractions and museums while he was mother but at the same time angry at his mother
recovering. When they went back to Manila, his for staying in the marriage and not protecting
father stopped calling him “best buddy” and he them.
became increasingly annoyed at him for
spending his time playing video games. Given the situation at home and in the classroom,
he often went to the guidance office to talk to
One time he was caught and reprimanded by his adults whom he felt understood him. He
father when he was playing with his genitals, admitted not knowing how to act around his
enveloping his penis into his scrotum pretending classmates, saying, “socially, I did not know what
to be a girl with his testicles as his labia. He got would make someone tic.” Even in his media
curious wondering what they were and what club, he was excluded by his clubmates and he
they were for. This curiosity further triggered would often do the projects alone. When a
every time he sat on the toilet, seeing his genital classmate started to become friends with him, he
looking like a grasshopper. Aside from his never thought of him as a friend but since he
genitals, he developed fondness for other parts was the only one who could tolerate him, he
of the body particularly when he saw his finally considered him a friend.

37 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

His classmates called him “super puppy Jay” in a At home, when he was not studying, he would
sing-song voice because sometimes he pretended draw, run, write music and make videos. He also
to be a dog and barked at others. One time, he took responsibility in taking care of his youngest
got mad at his friend for also teasing and calling brother since his other siblings were mostly out
him a puppy that he barked and chased him of the house with their friends.
around the classroom to expressed his anger. His
teacher thought they were playing around so When prom season came, he invited a girl from
they were asked to step out of class for their his tutor class for convenience. There were no
“Time Out” punishment. What frustrated him sparks felt and choosing her was solely for the
was that his teacher thought he was playing event. They had no further communication
when he was not. Jay’s parents dismissed his afterwards. It was a different story for his senior
grievances with school, never comforting and ball, wherein he asked a family friend he liked
reassuring him. He felt ignored by them. He whom he knew had a boyfriend. Confessing his
eventually quit the media club and decided to feelings for her, she responded with annoyance
join Boy Scouts, where he thrived and which he and avoidance.
enjoyed.
For college, Jay was set to take a pre-medical
At 11 years old, while he was using his uncle’s course as he wanted to become a medical
computer, a pop-up of pornographic material doctor. There were no reservations when
appeared. His interest was piqued as he browsed starting a conversation with random strangers
through the website, simulating the images by seated next to him, though he still did not have a
tying a shoelace on his penis. Upon ejaculation, specific group of friends. He never went to
his first experience of such sensation, he was parties because he did not like the bright and
filled with a mixture of pleasure and fear, flashing lights nor the music, which he
scared he was bleeding white blood. Despite the categorized as noise. College was the time he
pleasure, he never did the same act for fear of started pursuing romantic relationships. He
injuring his penis, but continued to visit recalled asking his female friends for dates, but
pornographic websites. all of them refused. Some of the girls he asked
out ended up avoiding him and stopped
At 12 years old, he started getting aroused when replying to his messages. Frustrated with failed
he played games involving slavery, chains, ropes courtships, he asked his two younger siblings for
and prisoners. He sometimes touched himself dating tips. Arming himself with new knowledge
after playing. One time, an innocent play with his on girls and dating, he confidently asked out a
female cousin led him to getting aroused when close friend for a date only to be immediately
he wrapped her with a blanket. On a different denied. After a series of rejections, he justified
occasion, while another female cousin was that his timing was off and stopped pursuing
sleeping, he had an impulse to tie her hands girls..
behind her back. This excited him and after a
few minutes, he untied her and slept beside her. Leaving home to stay near his medical school
As he thought she was just pretending to be was monumental since he was able to separate
asleep, he asked if she wanted to be tied again from his father. Despite wanting to physically
the next day. This cousin told his father about it free himself from his father, his choices and
and he was forbidden to do it again. actions showed otherwise—studying business to
connect with him and reading topics, in which
Jay never had problems with his academics and his father was interested. Almost every time he
became part of the honor’s class in high school. was with his family, he and his father would
Being active and intelligent, his teachers favored have a discourse on various topics particularly
him, resulting to classmates teasing him as about ethics and medicine. Jay’s father though,
“teacher’s pet.” The teasing extended to his short was dismissive of Jay’s thoughts and opinions,
stature, which made him self-conscious. He was leaving him hurt and disappointed.
seen as the prayer boy and nerd in class
preferring the Bible and Science over sports and In the first months of medical school, Jay did not
girls, which were his classmates’ interests. have friends. He preferred staying with his

38 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

assigned own groupmates, eventually becoming and fluent. Mood was euthymic with a flat affect.
close to the females whom he found easy to talk His responses were goal-directed and tends to be
to. fixated on matters that interest him. He was
preoccupied with the frequency of his intrusive
Classmates would comment he’s “one of the thoughts regarding his violent sexual fantasies.
girls,” which didn’t really bother him. He often He denied perceptual disturbances or delusions.
avoided leadership roles because he did not like He was oriented to 3 spheres with good attention,
keeping tabs on group members. Efforts to be concentration and abstract reasoning. He had
liked by his batchmates backfired, finding his intact immediate, recent and remote memory.
antics, weird and his behavior, odd. For There were no suicidal and homicidal ideations.
example, he would randomly join in the Impulse control was good with fair insight to his
conversation of other groups, or hide from his illness, acknowledging he needed to seek consult
classmates and suddenly jump in front of them but at the same time denying it was causing
to surprise them. One classmate talked to Jay problems.
about his behavior and until the time of consult,
he tried to be mindful of his actions whenever he Physical Examination
was with his classmates.
General Survey: Awake, alert, not in
Jay made excuses not to go home to his family on cardiorespiratory distress
weekends, holidays and summers because Vital Signs: BP 100/70 mmHg, HR 75, RR 16
according to him, he preferred not to break his Height: 150cm Weight: 55kg BMI: 24.44
daily routine. At times when he would have to (overweight for Asian)
deviate from his routine, it would take one to two Dermatologic: No rashes, no lesions
days for him to adjust again. HEENT: (+) hypopigmented hypertrophic scar 8-
9cm L parietal area. Anicteric sclerae, pink
Past Medical and Psychiatric History palpebral conjunctivae
Jay was diagnosed with Middle Clivus Chordoma Chest/Lungs: Symmetrical chest expansion, no
when he was 6 years old and had to undergo retractions, clear breath sounds in both lung
decompression, resection and radiation therapy. fields
He also was diagnosed with Trigeminal Cardiovascular: Adynamic precordium, apex
Neuralgia in 2010 after experiencing headaches beat at 5th intercostal space left midclavicular
and jaw pain after a tooth extraction. The pain line, normal rate and regular rhythm, no
significantly lessened on Carbamazepine 200mg murmur
a day, which he still takes at present. Abdomen: Flat, soft, non-tender
Extremities: No edema or cyanosis, full and
When he was 24 years old, he reported equal pulses.
depressive symptoms but never consulted with a Neurologic Examination:
professional. Cranial Nerves: Intact
Motor: No atrophy, hypertrophy; No tremors.
Mental Status Examination Motor strength 5/5 all extremities. Normal tone
Jay was seen and examined as an adult male of all muscles.
medium built and short stature looking younger Cerebellum: No nystagmus, dysmetria and
for chronological age. When he stepped into the dysdiadochokinesia
room, he had a sardonic smile on his face Sensory: 100% all extremities on light touch
greeting the examiner. He was fairly kempt
wearing his white school uniform with sneakers Psychiatric Rating Scales
and holding a heavy backpack. He had a stiff Patient Health Questionnaire-9 (PHQ-): 4 No
posture with a blank stare. His attitude toward depression
the examiner was peculiar suddenly showing Generalized Anxiety Disorder-7 (GAD-7) : 7
things like his stethoscope when talking about Mild anxiety
school, and not interested with what the Yale-Brown Obsessive-Compulsive Scale (Y-
examiner had to say. Speech was clear, BOCS): 23 moderate OCD symptoms
monotonous and normo-productive, preferring DSM 5 Level 2 Repetitive Thoughts and
to speak in English, with which he was articulate Behaviors-Adult: 1.2 Mild

39 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

 DSM 5 Self-Rated Level 1 Cross Cutting There are no attempts to ignore or suppress the
Symptom Measure Adult: thoughts, and no drive to perform repetitive
Personality Functioning- 4 severe (not behaviors or mental acts in response to the
feeling close to other people or enjoying intrusive thought. Furthermore, overall
relationships with them) functioning is not impaired being able to
Repetitive Thoughts & Behaviors- 3 perform his duties and school activities.
moderate (unpleasant thoughts, urges, or
images that repeatedly enter your mind; One of the most consistent findings in ASD is a
feeling drive to perform certain higher rate in males than females assumed to
behaviors or mental acts over and over have a ratio between 3 and 4 to 1. (3) Research
again) has also shown that the risk is highest in firstborn
Memory- 4 severe (problems with children and declines in each additional sibling
memory e.g. learning new information or born to the same mother. (4) Although nearly
with location e.g. finding your way home) half of individuals with ASD are not intellectually
Autism-Quotient Scale -26/50 (scores in the impaired and have normal cognitive and
26-32 range indicate some autistic traits language skills (such as individuals with high-
(Asperger syndrome) functioning autism or Asperger syndrome), the
Ritvo Autism Asperger Scale Diagnostic social interaction and communication deficits
Scale-revised -121 (RAADS-R score of 65 or and difficulties in seeing the perspective of
higher is consistent with a diagnosis of ASD) others and intuitively understanding nonverbal
social cues constitute hidden barriers to the
Initial Impression development of romantic and sexual
To Consider Obsessive Compulsive Disorder relationships. (5)
(OCD)
To Consider Autism Spectrum Disorder, without The majority of individuals with ASD go through
accompanying language and intellectual puberty and experience the same physical and
impairment (Asperger Syndrome) psychosexual aspects of sexual development as
Rule Out Sexual Sadism Disorder their peers. However, there are noted problems
with regards to sexuality especially at the start of
DISCUSSION puberty when the development of social skills
The diagnosis of Asperger Disorder in DSM-IV cannot keep up with the increasing social
TR is now classified under Autism Spectrum demands, and the difficulties of forming
Disorder (ASD) in DSM-5. The DSM-5 romantic and sexual relationships become
conceptualizes ASD as a continuum model, in evident. (2) Because of these deficits, they
which heterogeneity of symptoms is recognized usually have fewer friends, romantic partners or
as inherent in the disorders and core diagnostic sexual experiences than the typical developing
impairments are grouped into two domains: individual. As seen in the case, Jay desired for a
deficits in social communication, and restricted romantic relationship but every time he pursued
and repetitive behaviors. (1) From Jay’s history, someone, he was never successful. The series of
his persistent deficits in social communication, rejections did not discourage him to ask out
social interaction, and concreteness and rigidity other female friends who also rejected him and
were already present in the early developmental eventually avoided him completely. As for his
period, which still manifest until present. His sexual experiences, they were just thoughts in his
OCD-like symptoms such as recurrent and head, played out in his games, and acted out
persistent thoughts and images could actually be with female chatmates.
explained by the ASDs preoccupation with
restricted patterns of interest that are abnormal Having said that, individuals with ASD actually
in intensity or focus. OCD and ASD are often show the entire range of sexual behaviors just
misdiagnosed as one another. This is because the like neurotypical adults. There are still many
symptoms of both can overlap and look similar. misconceptions and stereotypes about ASD
OCD is ruled out in this case because there is no referring to them as uninterested in social and
presence of true obsessions and compulsions. romantic relationships, sexually immature,
There is denial of marked anxiety and obsession and/or as being asexual. There are several
over having intrusive thoughts. literatures confirming that sexuality and the

40 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

whole spectrum of sexual experiences and autism and paraphilia disorder is still unclear
behaviors do matter for them. However, even but there are neurobiological approaches
though they seek relationships and sexual emphasizing brain networks being disturbed in
intimacy, there is difficulty in maintaining them both disorders. (7)
due to the inherent deficits in social and
communication skills. It is very much affected by He stated that lesions in the
their understanding of nonverbal cues, rules of amygdalohippocampal region are thought to be
social interaction as well as being able to involved in autism as well as sadomasochism
understand one’s own and others’ mental states. and fetishism, although there are no definitive
(6) studies conducted. (7) Some studies have
proposed that features such as social deficits
A study done by Schöttle et al. in 2017, explained and preoccupations with restricted and
that due to the core symptoms of the disorder, repetitive interests may contribute to paraphilia-
including deficits in social skills, sensory hypo- related psychopathology. The study of
and hypersensitivities, and repetitive behaviors, Fernandes et al. in 2016 revealed that 24% of
some ASD individuals might develop high-functioning individuals with ASD engaged
quantitatively above-average or nonnormative in paraphilic sexual fantasies or behaviors
sexual behaviors and interests, just like Jay. (6) including classic presentations of paraphilic
Since part of the symptom is restricted, disorder such as pedophilia, voyeurism, and
repetitive interests and patterns of behavior, a sadomasochism. (8) These disorders then may
nonsexual activity or interest in childhood can be a co-morbid of ASD.
actually become sexualized when they become
adults. At a young age, Jay was already One should be mindful in diagnosing a
fascinated with his genital and other people’s paraphilic disorder. The term paraphilia
body part such as his househelp’s feet. He was denotes any intense and persistent sexual interest
getting sexually aroused at themes of slavery, other than sexual interest in genital stimulation
chains and ropes even though the context was or preparatory fondling with phenotypically
not sexual in nature. He also mentioned that normal, physically mature, consenting human
BDSM pornography was much more arousing partners. (1) These paraphilia or perversions
compared to normal pornography, which could are sexual stimuli that are deviations from
be ascribed to him having hyper- or hypo- society’s normal sexual behaviors but they are
reactivity to sensory input leading to different necessary for some people to experience arousal
responses to sensory stimuli and affecting his and orgasm. It becomes a disorder when it
sexual experience. Taken the core symptoms causes distress or impairment to the individual
together, there is a predisposition to have or a paraphilia whose satisfaction has entailed
challenging and problematic sexual behaviors personal harm, or risk of harm, to others. (9)
such as hypersexuality and paraphilia.
Acting out his fantasies, Jay was already risking
Very few studies have been published on ASD potential harm to his sexual partners. What was
and its relationship to paraphilia. Studies that helping him moderate his paraphilic urges was
have been carried out on sexuality and ASD his religion. There was distress when he thought
show that those diagnosed to have ASD have a of himself participating in these behaviors. To
wide variety of sexual behaviors. The findings of allay the guilt, he then would do penance by
Schöttle et al. (2017), showed individuals with involving himself in the school’s religious
ASD having more hypersexual and paraphilic organization.
fantasies and behaviors than healthy controls.
(6) A possible disregard to social norms A paraphilia is a necessary but not a sufficient
together with the hypersensitivities could condition for having a paraphilic disorder, and
increase the risk for engaging in nonnormative a paraphilia by itself does not qualify for
sexual behaviors to become sexually aroused; assignment of a psychiatric diagnosis and does
hence, individuals with ASD tend to suffer not necessarily justify or require clinical
paraphilic psychopathologies. intervention. The pathognomonic element of
paraphilias is the special fantasy with its
According to Müller (2011), the etiology of conscious and unconscious components with

41 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

sexual arousal and orgasm reinforcing the safer and more ethical practices. Critics of
fantasy or impulse. (1) BDSM have a more solid legal basis to raise
concerns about public health.
The DSM-5 lists pedophilia, frotteurism,
voyeurism, exhibitionism, sexual sadism, sexual In Bennett’s Sydney Law Review of 2013, he
masochism, fetishism and transvestism with mentioned some medical concerns involved with
explicit diagnostic criteria because of their the practice such as: possibility for the infection
threat to others and/or because they are of cuts, urinary tract infection, septicemia, and
relatively common paraphilias. (9) transmission of blood-borne pathogens such as
HIV/AIDS. (13) While consensual BDSM activities
Nevertheless, the prevalence of paraphilias is not are not prosecuted or policed, public health
well established in literature. A contributing concerns are apparent and must be taken into
factor is the reluctance on the part of the patient consideration by the community.
to disclose these behaviors as they are
embarrassing, and in some cases against the law. FINAL DIAGNOSIS
(10) Autism Spectrum Disorder without
accompanying language and intellectual
As per the DSM-5, the frequency of sexual impairment (Asperger Syndrome) & Sexual
masochism disorder is unknown. (9) Based on Sadism Disorder
the search of literatures, very few cases of
individuals with ASD and comorbid paraphilic Psychodynamics
disorder have been published. Jay is a 26-year-old Christian male incoming
medical clerk, seeking consult for his “intrusive
The role and development of paraphilias across thoughts.” Thoughts, which were violent and
cultures is variable, with cultures defining what sexual, were always there since childhood but
is legal or illegal. (11) This is because not all would only bother him when there was stress.
deviant or unusual sexual behaviors and Worrying he would act them out when clerkship
interests are pathological. However, there are starts finally led him to seek psychiatric consult.
potential legal consequences in most paraphilic Through the sessions, he was seen hungry for
disorders such as pedophilia, voyeurism, and answers to what was ultimately wrong with him,
exhibitionism. Sexual sadism usually comes to his question ever since.
attention only in sensational cases of rape,
brutality and lust murder. Born out of wedlock, the mistake of Jay’s young
parents was ensured that it would not to be
An important point to talk about is the increasing repeated again in the family. He has felt
interest and awareness of the practices of BDSM. unwanted by others from the day he was born
While BDSM sexuality encompasses a wide even by his own mother, choosing career over
variety of activities, a community of individuals nurturing him. Being a complex child, it was
interested in the practice is identifiable and has difficult for his young parents, having their own
coalesced around organized groups, events, issues, to understand Jay’s peculiarities as he
political activism and shared sexual interests, himself lacked awareness of other’s sensibilities.
challenging a lot of conservative views. The Early on, one can see Jay’s efforts to belong and
premise that BDSM is a deviation from be wanted, if not by his parents, his peers.
normative sexual behavior already leads to the Despite his efforts, he still could not develop
practice being pathologized. (12) meaningful and sustaining relationships. His
presenting issues and symptoms point to a deficit
A study done by Doshi in 2015 showed that in Mentalization—awareness of the others and of
engagement in BDSM was not significantly the self. It is the key to self-regulation and self-
related to any sexual difficulties rather it is direction, developing a sense of self that includes
simply a sexual interest and for most a sense of coherence, continuity and
participants or enthusiasts, it is not a responsibility for our choices and behavior.
pathological symptom of past abuse or difficulty
with “normal” sex. (11) Advocates call for Biologically, a higher-than-expected incidence
depathologizing unusual sexual interests such as of prenatal and perinatal complications occur in
BDSM and encourage joining communities for infants who are later diagnosed with ASD.

42 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

One of the significant prenatal risk factors Even in school, there were no friends to relate
associated with ASD is being the first-born baby. with or strengthen his emotional relations.
Perinatally, Jay had umbilical cord Classmates were not considered as friends but as
complications, which could have caused hypoxia playmates. Ergo, video games became his friend,
in his developing brain. Further insult happened where there was no need for social interaction.
to his young brain when he developed a rare Jay’s development of the self was impaired from
tumor clival chordoma. Since it was detected the beginning.
and resected early, the interventions done saved
Jay but it could also have caused lasting effects At a young age, he was fascinated by feet,
to his brain. themes of bondage and slavery, and tying. These
interests may have been nonsexual in childhood
Having parents who were mostly away working, but transformed into sexualized behaviors when
Jay’s lack of emotional engagement went he became an adult. He had a knack for
undetected. A genetic basis for ASD is now well- simulating the things he saw or observed, which
established; a high possibility his father is also in is a characteristic of childhood mentalizing in
the spectrum. His father, described to be rigid, the pretend mode. If only he had good enough
socially awkward and unable to express role models to mirror mental states in an
affection, might not have been unable to provide accurate and consistent manner, then maybe he
Jay an emotional mirroring and understanding would have understood sex, himself and others
other people’s mental states. Having her own in the context of social norms and a loving
issues with her husband and preoccupied relationship.
herself, his mother often dismissed his concerns
leaving Jay to find means to soothe himself. Being a devout Christian, there was guilt for
wanting to satisfy his carnal urges. Religion was
In Asperger’s syndrome, cognitive abilities and one of the things that remained constant and it
major adaptive skills are age appropriate. (1) was what helped in regulating his id impulses. He
What was impaired in him was his social would want to abide by the Bible’s teachings but
relatedness and repetitive and stereotyped has found it hard to comply because he also
patterns, which were not alarming to his parents. could not totally eliminate what has been giving
Though his mother noticed some odd behavior, him pleasure.
she thought nothing of it as her husband might
have exhibited similar symptoms. Moreover, Unconsciously, the repeated rejections and
there was difficulty mentalizing due to the abandonment he felt by family, friends,
dysfunctional mirror neuron system, which helps classmates, and girls led to reaction formation in
a developing brain understand the actions and his bondage & discipline, dominance &
intentions of others and understand other submission and sadism & masochism (BSDM)
people’s mental/emotional states. In those with acts: of being the dominatrix (i.e. a woman who
ASD, there is no activity in the pars opercularis takes the dominant role in BDSM sexual
region of the inferior frontal gyrus, a brain activities) himself. Though the thoughts and acts
region with identified mirror properties. (14) were short-lived, the power, aggression and
boldness it gave were enough to forget that he
Psychologically, the single most important factor was unwanted and unloved. As the aggressor
in fostering mentalizing is a secure attachment himself, he becomes like his father-- headstrong
relationship, which should have been the anchor and powerful. The desire to be in an intimate
of all his other adult relationships. Being young relationship is temporarily gratified, although
parents forced to marry, they had no experience awkwardly in his BDSM role plays.
in taking care of a newborn. Early on, there was
no constant attachment figure which failed to Biologically, the mentalizing region proper, the
yield a feeling of security for Jay. His mother left medial prefrontal cortex that is responsible for
him with his father who was unable to reading emotions in people’s faces is impaired in
emotionally provide for Jay. Growing up, his ASD. (14) Hence, he may need exaggerated
parents were emotionally distant except for the responses and facial expressions in his daily life
time he was ill and confined in a hospital in the and during BSDM encounters. His compulsive
USA, which were his fondest memories. There behaviors can be explained as a result of
was also difficulty relating with his siblings. impaired inhibitory control, a key executive

43 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

function of the prefrontal cortex, which delays Selective serotonin reuptake inhibitors (SSRIs)
reward and restricts impulsive acts. (15) This, have a role not only for Jay’s unwelcomed
together with problems in serotonin homeostasis, thoughts but also for impulsivity and aggression.
also implicated in ASD, led to poor impulse Serotonin is deeply involved in the regulation of
control and aggressive behavior. (1, 10) emotion and behavior, including inhibition of
aggression. Jay’s intrusive thoughts were noted to
A central problem with those who are diagnosed increase when he was stressed and studies have
with the autism spectrum is difficulty in shown stress-induced elevation in 5-HT
understanding their own mind and the mind of synthesis, a key counter-regulatory process
others. Inadvertently, the written agreement he disrupting the serotonergic homeostasis. (16) If
would ask his partners to sign before engaging started, this will decrease his libido especially
in sexual activities helps Jay read his partner. when thinking and watching BDSM-themed
However, the mentalizing problems of ASD are shows. Initiation of an SSRI was discussed with
understanding emotions and responding to Jay but he was hesitant since he did not want to
others’ distress, which may prove difficult for add another medication on top of his
him particularly knowing when to stop inflicting Carbamazepine. It was emphasized that if his
pain. Jay’s BSDM somehow has been his own thoughts and urges cause excessive anxiety and
desperate yet unhealthy attempt for emotional marked distress, starting an SSRI might be
connection. The therapist’s very act of trying to introduced again.
understand Jay within the context of the two-
person relationship during psychotherapy What may be currently helping in regulating his
becomes a way of reflecting emotions in a safe impulses and aggression is his use of
environment where he does not feel Carbamazepine, an anticonvulsant. At a
overwhelmed. neurochemical level, an imbalance of
gabaminergic systems is associated with
Given that Jay is on the high-functioning reactivity and aggression, reflecting a high
spectrum of ASD, he can be helped by arousal state underpinned by neuronal
emotionally coaching him how another person’s hyperexcitability. (17) Therefore, drugs which
mind reacts to the patient’s comments and reduce neuronal excitability and specifically
behavior. The goal is to help Jay learn to observe those classed as antiepileptics or anticonvulsants
his mind and action through the clear and could theoretically be expected to lower the
consistent tagging of emotions and mental states likelihood of reactive aggressive outburst. (18)
of the therapist herself. Researches have shown
that though individuals with Asperger’s cannot For now, he agreed to have regular follow-ups to
grasp the mental states in other persons improve his self-esteem, ego functions and
implicitly or automatically, they may be able to adaptive skills. Psychotherapy has a recognized
learn explicit mentalizing skills through value for Jay as his subjective experiences affect
concerted effort and help from others such as the brain. Any change in the psychological
assisting them to think about what the other processes is reflected by changes in the functions
person is thinking. or structures of the brain. (19)

For Jay, these interventions will help him work Cognitive Behavioral Therapy (CBT) and
toward self-acceptance and making connections Mentalization Based Therapy (MBT), are
through successful relationship ties. recommended for individuals with milder
symptoms of ASD, and may prove useful for Jay
MANAGEMENT as it can teach him cognitive restructuring, and
Few studies to date have made treatment social and emotional awareness in himself and
recommendations for patients with ASD and others. (14, 20, 21) CBT will focus on his issues
comorbid paraphilia. There is an undoubtedly that are related to the experience of life being on
difficult task for psychiatrists in figuring out the the autism spectrum: depression, bullying, stress,
appropriate management especially given the anger, aggression, anxiety, social skills deficits
limited information regarding pharmacological, and limited social support. (20) It will let the
and behavioral treatments for this unique therapist understand Jay’s perception of himself:
condition. his beliefs about himself, his personal world and

44 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

his future. REFERENCES
1. Sadock BJ, Sadock VA, Ruiz P. Kaplan & Sadock's synopsis of
psychiatry: Behavioral sciences/clinical psychiatry. 11TH
The ability to regulate his emotions and the edition. Philadelphia, PA: Wolters Kluwer; 2015.
accurate reading of how another person’s mind 2. Seltzer MM, Krauss MW, Shattuck PT, Orsmond G, Swe A,
reacts to his comments and behavior are at the Lord C. The symptoms of autism spectrum disorders in
adolescence and adulthood. J Autism Dev Disord.
core of MBT. (14) Therapy sessions thus give him 2003;33(6):565-581. doi:
the learning opportunity to observe his own 10.1023/b:jadd.0000005995.02453.0b. PMID: 14714927.
mind and action, through the emotional 3. Stokes MA, Kaur A. High-functioning autism and sexuality: a
parental perspective. Autism. 2005;9(3):266-289. doi:
perspective and feedback of his therapist,
10.1177/1362361305053258. PMID: 15937042.
including identifying social signals. 4. Cheslack-Postava K, Jokiranta E, Suominen A, Lehti V,
Sourander A, Brown AS. Variation by diagnostic subtype in
Jay is prone to stress being in the field of risk for autism spectrum disorders associated with maternal
parity among Finnish births. Paediatric and perinatal
medicine. Identifying his maladaptive emotional epidemiology. 2014; 28(1): 58–66. Available from:
distress, assumptions and coping may ultimately https://doi.org/10.1111/ppe.12094
give him new strategies and ways of dealing with 5. Howlin P, Mawhood L, Rutter M. Autism and developmental
receptive language disorder—a follow-up comparison in early
his issues particularly when it comes to his sexual
adult life. II: Social, behavioural, and psychiatric outcomes. J
thoughts and behavior. The very reason for Child Psychol Psychiatry. 2000;41(5):561-578. doi:
consult is the bothersome nature of his intrusive 10.1111/1469-7610.00643. PMID: 10946749.
thoughts which would frequently resurface when 6. Schöttle D, Briken P, Tuscher O, Turner D. Sexuality in
autism: hypersexual and paraphilic behavior in women and
he’s stressed. Improving stress management and men with high-functioning autism spectrum disorder,
mastering his own thoughts will help control Dialogues in clinical neuroscience. 2017; 19(4): 381-393. doi:
impulses and urges to engage in violent and 10.31887/DCNS.2017.19.4/dschoettle.
7. Müller J. Are sadomasochism and hypersexuality in autism
sexual acts. His difficulty in establishing
linked to amygdalohippocampal lesion? J Sex Med [Internet].
connections led him to seek unconventional 2011;8(11):3241-9. Available from:
methods to assuage this need. Through CBT, he https://onlinelibrary.wiley.com/doi/10.1111/j.1743-
will be given skills to relate better with other 6109.2009.01485.x
8. Fernandes LC, Gillberg CI, Cederlund M, Hagberg B, Gillberg
people and develop real friendships- mastering C, Billstedt E. Aspects of sexuality in adolescents and adults
social activities, rating pleasurable activities for diagnosed with autism spectrum disorders in childhood. J
him, mini accomplishments, cognitive imagining Autism Dev Disord. 2016 Sep; 46:3155–3165. doi:
10.1007/s10803-016-2855-9. PMID: 27401993.
and rehearsing, etc.
9. American Psychiatric Association. Diagnostic and statistical
manual of mental disorders DSM-5. 5th edition. Arlington,
Jay’s central issue is an attachment failure since VA: American Psychiatric Publishing; 2013.
childhood and his unhealthy attempts of 10. Kolta B & Rossi G. Paraphilic disorder in a male patient with
autism spectrum disorder: incidence of coincidence. Cureus.
attachment through his BDSM partners. With the 2018 May 16 ;10(5): e2639. doi: 10.7759/cureus.2639. PMID:
help of the therapist, he can untie the knots in his 30034961; PMCID: PMC6047840.
unhealthy relationships while strengthening the 11. Doshi Sunil M. BDSM: A Sexual Deviance Rather a Sexual
Culture An Overview. Journal of Indian Academy of Forensic
ties of healthier ones. Factoring his inherent
Medicine. 2015 April 9;37(1):78-81. doi: 10.5958/0974-
disability being as an ASD, the therapist can 0848.2015.00019.6.
provide an emotional reference to the myriad of 12. Iannotti Larry. I Didn't Consent to That: Secondary Analysis
social experiences. He can learn a wider set of of Discrimination Against BDSM Identified Individuals. CUNY
Academic Works. 2014. Available at:
behavioral and facial repertoires through the https://academicworks.cuny.edu/gc_etds/229
therapist’s modelling, which he can practice in 13. Bennett T. Sadomasochism under the Human Rights (Sexual
his immediate social circle like his family and Conduct) Act 1994. Sydney Law Review. 2013;35(3): 541-564.
Available from:
friends, without diving into the more complex
http://classic.austlii.edu.au/au/journals/SydLawRw/2013/22.
world of BSDM. His other gifts like his pdf
intelligence, religiousness, and healthy ambitions 14. Allen JG, Fonagy P, Bateman A. Mentalizing in clinical
to be a doctor can be encouraged. This in turn practice. Washington, DC: American Psychiatric Pub.; 2008. ‌
15. Zhao HC, Lv R, Zhang GY, He LM, Cai XT, Sun Q, et al.
can provide channels for sublimations for his Alterations of prefrontal-posterior information processing
sexual fantasies and urges, while also providing patterns in Autism Spectrum Disorders. Frontiers in
safe and wholesome opportunity to learn social Neuroscience. 2022 Jan 31;15.
16. Chaouloff F, Berton O, Mormède P. Serotonin and stress.
cues and context.
Neuropsychopharmacology. 1999 Aug;21(2 Suppl):28S-32S.
doi: 10.1016/S0893-133X(99)00008-1. PMID: 10432486.
17. Haller J, Kruk MR. Normal and abnormal aggression: human
disorders and novel laboratory models. Neuroscience and
Biobehavioral Reviews 2006;30(3):292–303.

45 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

doi: 10.1016/j.neubiorev.2005.01.005. PMID: 16483889.
18. Huband N, Ferriter M, Nathan R, Jones H. Antiepileptics for
aggression and associated impulsivity. Cochrane Database of
Systematic Reviews. 2010 Feb 17;2010(2):CD003499. doi:
10.1002/14651858.CD003499.pub3. PMID: 20166067; PMCID:
PMC4163499.
19. Ramy H. The biology of cognitive behavior therapy, European
Psychiatry.2017 Apr; 41 (S1): S637.
doi:10.1016/j.eurpsy.2017.01.1047.
20. Creed T. An introduction to CBT for people with an autism
spectrum disorder. 2015. Available at:
https://beckinstitute.org/blog/an-introduction-to-cbt-for-
people-with-an-autism-spectrum-disorder/
21. Krämer K, Vetter A, Schultz-Venrath U, Vogeley K, Reul S.
Mentalization-based treatment in groups for adults with Autism
Spectrum Disorder. Frontiers in Psychology. 2021 Aug 12;12. doi:
10.3389/fpsyg.2021.708557

46 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

 PJP ABSTRACT

CLINICAL EXPERIENCE WITH PALIPERIDONE PALMITATE IN A SPECIALTY

HOSPITAL IN THE PHILIPPINES:
A SHORT REPORT
AMADEO A. ALINEA, JR., MD, FPPA*
CARL ABELARDO T. ANTONIO
AMIEL NAZER C. BERMUDEZ
KIM L. COCHON
MARIA FATIMA V. MARTINEZ, MD
JONATHAN P. GUEVARRA

ABSTRACT

OBJECTIVES: This study aimed to describe the clinical outcomes related to the
introduction of Paliperidone Palmitate in a specialty hospital in the Philippines.

METHODOLOGY: Cross-sectional study among patients with Schizophrenia seen at the

psychiatry service of a specialty hospital catering to war veterans who were initiated on
Paliperidone Palmitate. We reviewed and abstracted baseline patient data from the
medical record of eligible patients. Outcome of treatment was collected through a one-
time objective assessment of the patient by a third-party psychiatrist using the
Structured Clinical Interview for Symptoms of Remission (SCI-SR) tool.

RESULTS: A total of 30 patients were recruited for the study from August 2020 and June
2021, the majority of whom were males (80%), residents of the National Capital Region
(50%) and single (20%). The median duration from schizophrenia diagnosis to initiation of
Paliperidone treatment was 19.50 years (IQR: 16.60 – 33.50). In eight patients (22.67%),
other antipsychotic drugs were discontinued following initiation of Paliperidone
treatment; in the remaining 22 participants (73.33%), Paliperidone was taken concurrently
with other antipsychotic drugs. The median duration from the initiation of Paliperidone
treatment to follow-up assessment was 27.20 months (IQR: 24.73 – 30.50), with all
participants having at least 6 months of treatment. At follow-up assessment, all
participants were classified to be in remission.

CONCLUSION: In this study among patients with schizophrenia seen in a specialty

hospital in the Philippines, we found evidence that clinical outcomes with Paliperidone
Palmitate were comparable to those given a combination of oral and long- acting
antipsychotics.

KEYWORDS: Paliperidone palmitate, Schizophrenia

*Department of Psychiatry Veterans Memorial Medical Center, Quezon City, Philippines

Corresponding author: [email protected]
Disclosure: Funded by Johnson &amp; Johnson (Philippines), Inc.

49 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

 PJP ABSTRACT

PROFILE OF NATIONAL CENTER FOR MENTAL HEALTH (NCMH)

EMPLOYEES‘ DEPENDENTS ON INTERNET
USE
RAYMOND JOSEPH S. VALDEZ, MD
GIA PAULINE S CASTILLO- MOJICA, MD
VENUS SERRA-ARAIN, MD, FPPA, MHA

ABSTRACT

OBJECTIVES: This study aimed to determine the sociodemographic profile and the
prevalence of internet use among the NCMH employees’ dependents.

METHODOLOGY: This was a descriptive study of NCMH employees’ dependents from10-

40 years old who lived in the same household and spoke English, selecting them through
random sampling and using the 8 -item Internet Addiction Diagnostic Questionnaire. Only
non-essential computer / internet usage was evaluated and addiction was considered
present if patient answered 5 or ore of the questions over a 6- month period.

RESULTS: There were 100 respondents who qualified with 52% females and 48% males.
Eighty five percent were 30 years old and below but almost equally distributed between
those from 10- 20 years old (45%) and those from 21- 30 years old (40%); but most of
them (45%) had reached college though not all graduated (38%). Majority (83% ) were
Roman Catholics and 76% were single. There were 78 (78%) respondents who had
problematic internet use.

CONCLUSION: The prevalence of problematic internet use among dependents of NCMH

employees was quite high.

48 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

 PJP FOR CONTRIBUTORS

INFORMATION FOR CONTRIBUTORS TO THE PHILIPPINE JOURNAL

OF PSYCHIATRY 2017

The Philippine Journal of Psychiatry is a 2) A statement of financial or other

referred journal designed to meet the relationships that might lead to a conflict of
continuing education needs of practicing interest, if that information is not included in
psychiatrists in the Philippines. It is published the manuscript itself or in an authors’ form.
under the auspices of the Philippine
Psychiatric Association. The Philippine Journal 3) A statement that the manuscript has been
of Psychiatry accepts only original and read and approved by all the authors, that the
unpublished articles on psychology, requirements for authorship as stated earlier
psychiatry and other behavioral sciences with in this document have been met, and that
the understanding that that they have not each author believes that the manuscript
been published previously, nor being reviewed represents honest work.
or considered for publication elsewhere,
either as a whole or any substantial part. 4) The full name, postal & email address, cell
phone and telephone number of the
The corresponding author should inform the corresponding author, who is responsible for
editor in chief about all submissions to other communicating with the other authors about
publications and any previous reports that revisions and final approval of the proofs as
might be considered prior or duplicate well as with the editorial board of the PJP.
publications- including data or observations
already reported or patients already SUBMISSION OF MANUSCRIPTS
described- and should include copies of such Hard copy of manuscripts may be submitted
material for the editor to examine. in duplicate, typewritten using Times New
Manuscripts must be accompanied by a cover Roman font 11, double spaced with a minimum
letter, which should include the ff information: of 1.5” for margins on 8” x 11” (letter or short)
bond paper. All pages should be numbered. An
1) A full statement to the editor about all electronic form of the manuscript should be
submissions and previous reports that might stored in a document file- CD ReWritable disk
be regarded as redundant publication of the using Microsoft Word Program and submitted
same or very similar work. Any such work along with the duplicate hard copy. Send all
should be referred to specifically and copies of manuscript to the Editor- in -Chief or
referenced in the new paper. Copies of such to the PPA office. Please include all contact
material should be included with the numbers (residence & office telephone #, fax
submitted paper to help the editor address #, cell phone # and addresses (email,
the situation. residence/ office/ clinic) of the corresponding

49 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

 PJP FOR CONTRIBUTORS

author as well as the email & office/ clinic All forms of financial support, including drug
address and cell phone & landline telephone company support, are listed in the
numbers of ALL authors on the envelope acknowledgments section of the paper.
containing the manuscripts and disk.
Any affiliations or financial interests related to
REVIEW PROCESS subjects or services described in the paper- such
Manuscripts submitted to the PJP are sent for as employment, consultancies, stock ownership, or
blind review to at least 3 reviewers within a honoraria- or any financial relationships that may
week from date of receipt. The reviewers are suggest conflict of interest, are described. Such
given 2-4 weeks to review the manuscript. The interests do not mean automatic rejection of the
suggestions for revision are summarized and manuscript however they must be disclosed for
sent to the author for revision. A second or the editor’s information and for possible
third blind review may ensue until the paper is disclosure to reviewers.
deemed publishable by the editorial board.
The paper is then edited and shown to PREPARATION OF MANUSCRIPTS FOR RESEARCH
corresponding author prior to publication.The PAPERS, BRIEF REPORTS, LITERATURE REVIEWS &
corresponding author is encouraged to check SPECIAL ARTICLES
the edited manuscript for any errors, to answer
any queries of the manuscript editor or clarify Types of articles that can be submitted for
some details in the manuscript. Manuscripts publication to the Philippine Journal of Psychiatry
are accepted with the understanding that they are research reports, brief reports, literature
will be edited for clarity, elimination of reviews, special articles, case reports,
redundancy and conformity with the PJP commentaries, book reviews, monographs, letters
standards. and others.

DISCLOSURE & COPYRIGHT POLICY Manuscript may be submitted in English or

When paper is accepted, the Editor will send Pilipino, type written using New Times Roman font
the corresponding author an agreement and of 11 single spaced and with 1” margins on all sides
authorization from that states in essence that of 8” x 11” sized paper. Number the pages
the material is original, legal and has not been consecutively, placing the page number at the
previously published; that consent from all the lower right hand corner of each page, beginning
authors, when required, for permission to with the title page. The manuscript should be
publish has been obtained; that both the arranged as the ff: 1) Title, 2) Structured Abstract,
Philippine Journal of Psychiatry and the 3) Text, 4) Acknowledgments, 5) References, 6)
Philippine Psychiatric Association are harmless Tables & 7) Appendices. Enclose disclosure and
against any suit arising out of any alleged transfer of copyright duly signed by all the authors
breach of these warranties; that each of the and keep copies of everything submitted. The
authors has full responsibility for the content manuscript must be accompanied by copies of any
of the manuscript; and that the author permission to reproduce published material, to
authorizes the Philippine Psychiatric use illustrations or report information about
Association to publish the article and have the identifiable people or to name people for their
copyright. contributions.

50 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

 PJP FOR CONTRIBUTORS

Manuscripts may be sent through email to the of the study or observations and funding
PPA office, the Editor in Chief and/or the sources. The abstract should not exceed 250
Manuscript Editor. words and list up to 5 key words under which
article will be indexed.
I. Title Page should include a concise and
informative title, author’s name with highest III. Text should consist of Introduction,
academic degree as well as the name of Methods, Results and Discussion.
institution to which work can be attributed or
where research study was conducted. The title A. The INTRODUCTION should provide the
should include the study design especially for context and rationale or the study i.e. nature
randomized controlled trials i.e. any research of the problem and its significance. State the
project that prospectively assigns human specific purpose or research objectives of or
subjects to intervention or concurrent hypothesis being tested by the study. The
comparison or control groups to study the research objective may be stated as a
cause and effect relationship between a question.
medical intervention and a health outcome.
B. The METHODOLOGY section should
Include the name, telephone & cell phone describe how and why the study was done in a
numbers, mailing & email addresses of the particular way in as much detail about the
author responsible for correspondence about Study Design and with enough Technical
the manuscript and the author to whom Information that would allow others to
requests for reprints should be addressed. reproduce the results.

Sources of support in the form of grants, Methods for Selection of study population i.e.
equipment, drugs or all these should also be inclusion & exclusion criteria, data collection,
included. If paper was presented at a national and data analysis procedure should be
or international meeting, full details of the concisely yet easily understandable to the
meetings should be stated such as title, place readers.
and date.
Description of Study Participants should
II. Structured ABSTRACT should include: include the Source Population, explain
OBJECTIVES- purpose of the study or research relevance of inclusion / exclusion criteria and
question; METHODOLOGY- study design, demographic variables chosen e.g. why choose
selection process, setting, subjects, to study only women from 40- 60 years old.
observational and analytical methods, How variables were measured may also be
intervention(s) if any and main outcome important to specify.
measure(s); RESULTS- main findings of
research in relation to objectives stated and Describe the Statistical Methods with enough
give the statistical significance of detail to enable knowledgeable reader with
observations; & CONCLUSION- primary access to the original data to verify the
conclusions with emphasis on new and reported results. When possible, quantify
important aspects findings and present them with appropriate

51 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

 PJP FOR CONTRIBUTORS

indicators of measurement error or each table column and brief title for each
uncertainty i.e. confidence intervals. Define table above the table.Explanation or
statistical terms, abbreviations and symbols discussion of results in the table should be
used as well as specify the computer software placed before the Table and place Table
used. number referred to after paragraph where it is
mentioned e.g. (Table 1).
Ethical Considerations for the protection of
human subjects and animals in the research Figures should be as self explanatory as
should be indicated as when informed consent possible. Figures accepted for publication
was obtained and if the procedures followed must be clear, uncluttered, and two-
were in accordance with the ethical standards dimensional. Figure number and title should
of the responsible committee on human be placed below the figure. Explanations for
experimentation (institutional and national) as the Figures are placed after the Figure and
well as with the Helsinki Declaration of 1975 as indicate in parenthesis which Figure was being
revised in 2008. Do not use patient’s names, described e.g. (Figure 2)
initials, or hospital numbers, especially in
illustrative material. For x-ray films, scans and other diagnostic
images as well as pictures of pathology
C. The RESULTS should report only the specimens or photomicrographs, send sharp,
findings related directly to the research glossy, black and white or color photographic
objectives. Give numeric results as absolute prints 5 x 7 inches or 127 x 173 mm in camera
numbers and as percentages as well as how ready form. The names of the authors should
they were statistically analyzed. Use metric or be written at the back of each plate.
S.I. units of measurement and specify all units
of measurement clearly. Use only standard Photomicrographs should have internal scale
abbreviations. markers. Titles and detailed explanations
should be placed in the legends not on the
Include Tables & Figures only if they present illustrations themselves. Explain the internal
relevant numerical data more clearly than scale and identify the method of staining in
could be done in the text. Do not repeat all the photomicrographs.
data in tables, graphs or illustrations in the
text, where only the most important When symbols, arrows, numbers or letters are
observations are summarized. Label tables & used to identify parts of the illustrations,
figures appropriately and number identify
consecutively in order of their first citation in and explain each one clearly in the legend.
the text using Arabic numerals. Be sure that Please list on a separate page, values for the
each table and figure is cited in the text data points shown on graphs, in case the
otherwise don’t include it. reviewers/editors of the journal has to
recreate some figures. When reporting
Cell alignment of Tables should be to top left, statistically significant results, always report
single spaced or autofitted to contents of cell the observed test statistic value, degrees of
with all grid lines visible. Place a heading for freedom, probability level, and for t & F tests,

52 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

 PJP FOR CONTRIBUTORS

whether repeated measures were used. these to material that has already been
published, accepted for publication or
Supplementary materials and technical detail presented at a major national meeting.
can be placed in an APPENDIX where they will
be accessible but do not interrupt the flow of Citations of material in press must include
the text. Appendices are numbered in journal or publisher’s name followed by “in
sequence of how they are referred to in the press” or forthcoming”. If unpublished
text e.g. (Appendix 3). Checklists and material is cited indicate source and year in
questionnaires are generally not published. parenthesis in the text or written as a
footnote.
D. The DISCUSSION should emphasize the new
and important aspects of the study and the Avoid citing a “personal communication“
conclusions that follow from them. Link the unless it provides essential information
conclusions with the goals of the study but unavailable from a public source, in which
avoid unqualified statement or conclusions case the name of the person and date of
not supported by your data. communication should be cited in
Recommendations when appropriate may be parentheses in the text. For scientific articles,
included. Do not repeat study results in the obtain written permission and confirmation of
discussion but rather give explanations for the accuracy from the source of a personal
findings, compare and contrast the results communication.
with other relevant studies and state the
limitations of the study. Explore the Avoid using abstracts as references. Accuracy
implications of the findings for future research of the citation is the author’s responsibility.
and for clinical practice. Abbreviations of journal names should
conform to those used in Index Medicus.
E. ACKNOWLEDGMENTS. Disclosure
statements of sponsoring body may be Examples:
required for studies promoting products or
services described in the paper. One or more Articles in Journals (see also #36. Journal
statements should specify contributions that article on the Internet)
need acknowledging but do not justify
authorship such as emotional, financial, 1. Standard journal article
material or technical support. The List All authors if 6 or less: Surname and
corresponding author should submit the initials of all authors, tile of article, name of
written permission to be acknowledged from journal, year, volume & first and last pages.
all acknowledged individuals before printing. Halpern SD, Ubel PA, Caplan AL. Solid-organ
transplantation in HIV-infected patients. N
F. REERENCES: Only relevant references, Engl J Med. 2002 Jul 25;347(4):284-7.
preferably from original researches should be
cited in the text and listed according to their
order of appearance in the text using Arabic
numerals in parenthesis or superscript. Limit

53 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

 PJP FOR CONTRIBUTORS

If more than six authors, list only the first 6 of multi-species conserved sequences.
authors and add “et al”: Genome Res. 2003 Dec;13(12):2507-18.
Rose ME, Huerbin MB, Melick J, Marion DW,
Palmer AM, Schiding JK, et al. Regulation of 4. No author given
interstitial excitatory amino acid 21st century heart solution may have a sting in
concentrations after cortical contusion injury. the tail. BMJ. 2002;325(7357):184.
Brain Res. 2002;935(1-2):40-6.
5. Article not in English
Optional addition of a database's unique Ellingsen AE, Wilhelmsen I. Sykdomsangst
identifier for the citation: blant medisin- og jusstudenter. Tidsskr Nor
Forooghian F, Yeh S, Faia LJ, Nussenblatt RB. Laegeforen. 2002;122(8):785-7. Norwegian.
Uveitic foveal atrophy: clinical features and
associations. Arch Ophthalmol. 2009 Optional translation of article title
Feb;127(2):179-86. PubMed PMID: 19204236; (MEDLINE/PubMed practice):
PubMed Central PMCID: PMC2653214. Ellingsen AE, Wilhelmsen I. [Disease anxiety
among medical students and law students].
Optional addition of a clinical trial registration Tidsskr Nor Laegeforen. 2002 Mar
number: 20;122(8):785-7. Norwegian.
Trachtenberg F, Maserejian NN, Soncini JA,
Hayes C, Tavares M. Does fluoride in 6. Volume with supplement
toothpaste prevent future caries in children? J Geraud G, Spierings EL, Keywood C.
Dent Res. 2009 Mar;88(3):276-9. PubMed Tolerability and safety of frovatriptan with
PMID: 19329464. ClinicalTrials.gov registration short- and long-term use for treatment of
number: NCT00065988. migraine and in comparison with sumatriptan.
Headache. 2002;42 Suppl 2:S93-9.
2. Organization as author
Diabetes Prevention Program Research Group. 7. Issue with supplement
Hypertension, insulin, and proinsulin in Glauser TA. Integrating clinical trial data into
participants with impaired glucose tolerance. clinical practice. Neurology. 2002;58(12 Suppl
Hypertension. 2002;40(5):679-86. 7):S6-12.

3. Both personal authors and organization as

author (List all as they appear in the byline.) 8. Volume with part
Vallancien G, Emberton M, Harving N, van Abend SM, Kulish N. The psychoanalytic
Moorselaar RJ; Alf-One Study Group. Sexual method from an epistemological viewpoint. Int
dysfunction in 1,274 European men suffering J Psychoanal. 2002; 83(Pt 2):491-5.
from lower urinary tract symptoms. J Urol.
2003;169(6):2257-61. 9. Issue with part
Ahrar K, Madoff DC, Gupta S, Wallace MJ, Price
Margulies EH, Blanchette M; NISC RE, Wright KC. Development of a large animal
Comparative Sequencing Program, Haussler D, model for lung tumors. J Vasc Interv Radiol.
Green ED. Identification and characterization 2002;13(9 Pt 1):923-8.

54 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

 PJP FOR CONTRIBUTORS

10. Issue with no volume 15. Article retracted

Banit DM, Kaufer H, Hartford JM. Feifel D, Moutier CY, Perry W. Safety and
Intraoperative frozen section analysis in tolerability of a rapidly escalating dose-
revision total joint arthroplasty. Clin Orthop. loading regimen for risperidone. J Clin
2002;(401):230-8. Psychiatry. 2000;61(12):909-11. Retraction in:
Feifel D, Moutier CY, Perry W. J Clin
11. No volume or issue Psychiatry. 2002;63(2):169.
Outreach: bringing HIV-positive individuals
into care. HRSA Careaction. 2002 Jun:1-6. 16. Article republished with corrections
Mansharamani M, Chilton BS. The
12. Pagination in roman numerals reproductive importance of P-type ATPases.
Chadwick R, Schuklenk U. The politics of Mol Cell Endocrinol. 2002;188(1-2):22-5.
ethical consensus finding. Bioethics. Corrected and republished from: Mol Cell
2002;16(2):iii-v. Endocrinol. 2001;183(1-2):123-6.

13. Type of article indicated as needed 17. Article with published erratum
Tor M, Turker H. International approaches to Malinowski JM, Bolesta S. Rosiglitazone in the
the prescription of long-term oxygen therapy treatment of type 2 diabetes mellitus: a critical
[letter]. Eur Respir J. 2002;20(1):242. review. Clin Ther. 2000;22(10):1151-68;
discussion 1149-50. Erratum in: Clin Ther.
Lofwall MR, Strain EC, Brooner RK, Kindbom 2001;23(2):309.
KA, Bigelow GE. Characteristics of older
methadone maintenance (MM) patients 18. Article published electronically ahead of
[abstract]. Drug Alcohol Depend. 2002;66 the print version
Suppl 1:S105. Yu WM, Hawley TS, Hawley RG, Qu CK.
Immortalization of yolk sac-derived precursor
14. Article containing retraction cells. Blood. 2002 Nov 15;100(10):3828-31.
Feifel D, Moutier CY, Perry W. Safety and Epub 2002 Jul 5.
tolerability of a rapidly escalating dose-
loading regimen for risperidone. J Clin Books and Other Monographs
Psychiatry. 2002;63(2):169. Retraction of: 19. Personal author(s)
Feifel D, Moutier CY, Perry W. J Clin Murray PR, Rosenthal KS, Kobayashi GS,
Psychiatry. 2000;61(12):909-11. Pfaller MA. Medical microbiology. 4th ed. St.
Louis: Mosby; 2002.
Article partially retracted:
Starkman JS, Wolter C, Gomelsky A, Scarpero 20. Editor(s), compiler(s) as author
HM, Dmochowski RR. Voiding dysfunction Gilstrap LC 3rd, Cunningham FG, VanDorsten
following removal of eroded synthetic mid JP, editors. Operative obstetrics. 2nd ed. New
urethral slings. J Urol. 2006 Sep;176(3):1040- York: McGraw-Hill; 2002.
4. Partial retraction in: Starkman JS, Wolder
CE, Gomelsky A, Scarpero HM, Dmochowski
RR. J Urol. 2006 Dec;176(6 Pt 1):2749.

55 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

 PJP FOR CONTRIBUTORS

10. Issue with no volume 15. Article retracted

Banit DM, Kaufer H, Hartford JM. Feifel D, Moutier CY, Perry W. Safety and
Intraoperative frozen section analysis in tolerability of a rapidly escalating dose-
revision total joint arthroplasty. Clin Orthop. loading regimen for risperidone. J Clin
2002;(401):230-8. Psychiatry. 2000;61(12):909-11. Retraction in:
Feifel D, Moutier CY, Perry W. J Clin
11. No volume or issue Psychiatry. 2002;63(2):169.
Outreach: bringing HIV-positive individuals
into care. HRSA Careaction. 2002 Jun:1-6. 16. Article republished with corrections
Mansharamani M, Chilton BS. The
12. Pagination in roman numerals reproductive importance of P-type ATPases.
Chadwick R, Schuklenk U. The politics of Mol Cell Endocrinol. 2002;188(1-2):22-5.
ethical consensus finding. Bioethics. Corrected and republished from: Mol Cell
2002;16(2):iii-v. Endocrinol. 2001;183(1-2):123-6.

13. Type of article indicated as needed 17. Article with published erratum
Tor M, Turker H. International approaches to Malinowski JM, Bolesta S. Rosiglitazone in the
the prescription of long-term oxygen therapy treatment of type 2 diabetes mellitus: a critical
[letter]. Eur Respir J. 2002;20(1):242. review. Clin Ther. 2000;22(10):1151-68;
discussion 1149-50. Erratum in: Clin Ther.
Lofwall MR, Strain EC, Brooner RK, Kindbom 2001;23(2):309.
KA, Bigelow GE. Characteristics of older
methadone maintenance (MM) patients 18. Article published electronically ahead of
[abstract]. Drug Alcohol Depend. 2002;66 the print version
Suppl 1:S105. Yu WM, Hawley TS, Hawley RG, Qu CK.
Immortalization of yolk sac-derived precursor
14. Article containing retraction cells. Blood. 2002 Nov 15;100(10):3828-31.
Feifel D, Moutier CY, Perry W. Safety and Epub 2002 Jul 5.
tolerability of a rapidly escalating dose-
loading regimen for risperidone. J Clin Books and Other Monographs
Psychiatry. 2002;63(2):169. Retraction of: 19. Personal author(s)
Feifel D, Moutier CY, Perry W. J Clin Murray PR, Rosenthal KS, Kobayashi GS,
Psychiatry. 2000;61(12):909-11. Pfaller MA. Medical microbiology. 4th ed. St.
Louis: Mosby; 2002.
Article partially retracted:
Starkman JS, Wolter C, Gomelsky A, Scarpero 20. Editor(s), compiler(s) as author
HM, Dmochowski RR. Voiding dysfunction Gilstrap LC 3rd, Cunningham FG, VanDorsten
following removal of eroded synthetic mid JP, editors. Operative obstetrics. 2nd ed. New
urethral slings. J Urol. 2006 Sep;176(3):1040- York: McGraw-Hill; 2002.
4. Partial retraction in: Starkman JS, Wolder
CE, Gomelsky A, Scarpero HM, Dmochowski
RR. J Urol. 2006 Dec;176(6 Pt 1):2749.

56 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

 PJP FOR CONTRIBUTORS

21. Author(s) and editor(s) on Genetic Programming; 2002 Apr 3-5;

Breedlove GK, Schorfheide AM. Adolescent Kinsdale, Ireland. Berlin: Springer; 2002. p.
pregnancy. 2nd ed. Wieczorek RR, editor. 182-91.
White Plains (NY): March of Dimes Education
Services; 2001. 26. Scientific or technical report
Issued by funding/sponsoring agency:
22. Organization(s) as author Yen GG (Oklahoma State University, School of
Advanced Life Support Group. Acute medical Electrical and Computer Engineering,
emergencies: the practical approach. London: Stillwater, OK). Health monitoring on vibration
BMJ Books; 2001. 454 p. signatures. Final report. Arlington (VA): Air
Force Office of Scientific Research (US), Air
American Occupational Therapy Association, Force Research Laboratory; 2002 Feb. Report
Ad Hoc Committee on Occupational Therapy No.: AFRLSRBLTR020123. Contract No.:
Manpower. Occupational therapy manpower: F496209810049.
a plan for progress. Rockville (MD): The
Association; 1985 Apr. 84 p. Issued by performing agency:

National Lawyers’ Guild AIDs Network (US); Russell ML, Goth-Goldstein R, Apte MG, Fisk
National Gay Rights Advocates (US). AIDS WJ. Method for measuring the size distribution
practice manual: a legal and educational guide. of airborne Rhinovirus. Berkeley (CA):
2nd ed. San Francisco: The Network; 1988. Lawrence Berkeley National Laboratory,
Environmental Energy Technologies Division;
23. Chapter in a book 2002 Jan. Report No.: LBNL49574. Contract
Meltzer PS, Kallioniemi A, Trent JM. No.: DEAC0376SF00098. Sponsored by the
Chromosome alterations in human solid Department of Energy.
tumors. In: Vogelstein B, Kinzler KW, editors.
The genetic basis of human cancer. New York: 27. Dissertation
McGraw-Hill; 2002. p. 93-113. Borkowski MM. Infant sleep and feeding: a
telephone survey of Hispanic Americans
24. Conference proceedings [dissertation]. Mount Pleasant (MI): Central
Harnden P, Joffe JK, Jones WG, editors. Germ Michigan University; 2002.
cell tumours V. Proceedings of the 5th Germ
Cell Tumour Conference; 2001 Sep 13-15; 28. Patent
Leeds, UK. New York: Springer; 2002. Pagedas AC, inventor; Ancel Surgical R&D Inc.,
assignee. Flexible endoscopic grasping and
25. Conference paper cutting device and positioning tool assembly.
Christensen S, Oppacher F. An analysis of United States patent US 20020103498. 2002
Koza's computational effort statistic for Aug 1.
genetic programming. In: Foster JA, Lutton E,
Miller J, Ryan C, Tettamanzi AG, editors. Other Published Material
Genetic programming. Euro GP 2002: 29. Newspaper article
Proceedings of the 5th European Conference Tynan T. Medical improvements lower

57 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

 PJP FOR CONTRIBUTORS

homicide rate: study sees drop in assault rate. Tian D, Araki H, Stahl E, Bergelson J, Kreitman
The Washington Post. 2002 Aug 12;Sect. A:2 M. Signature of balancing selection in
(col. 4). Arabidopsis. Proc Natl Acad Sci U S A.
Forthcoming 2002.
30. Audiovisual material
Chason KW, Sallustio S. Hospital preparedness Electronic Material
for bioterrorism [videocassette]. Secaucus 35. CD-ROM
(NJ): Network for Continuing Medical Anderson SC, Poulsen KB. Anderson's
Education; 2002. electronic atlas of hematology [CD-ROM].
Philadelphia: Lippincott Williams & Wilkins;
31. Legal Material 2002.
Public law:
Veterans Hearing Loss Compensation Act of 36. Journal article on the Internet
2002, Pub. L. No. 107-9, 115 Stat. 11 (May 24, Abood S. Quality improvement initiative in
2001). nursing homes: the ANA acts in an advisory
role. Am J Nurs [Internet]. 2002 Jun [cited
Unenacted bill: 2002 Aug 12];102(6):[about 1 p.]. Available
Healthy Children Learn Act, S. 1012, 107th from:http://www.nursingworld.org/AJN/2002/j
Cong., 1st Sess. (2001). une/Wawatch.htmArticle
Code of Federal Regulations:
Cardiopulmonary Bypass Intracardiac Suction Optional presentation (omits bracketed
Control, 21 C.F.R. Sect. 870.4430 (2002). phrase that qualifies the journal title
abbreviation):
Hearing: Abood S. Quality improvement initiative in
Arsenic in Drinking Water: An Update on the nursing homes: the ANA acts in an advisory
Science, Benefits and Cost: Hearing Before the role. Am J Nurs. 2002 Jun [cited 2002 Aug
Subcomm. on Environment, Technology and 12];102(6):[about 1 p.]. Available
Standards of the House Comm. on Science, from:http://www.nursingworld.org/AJN/2002/j
107th Cong., 1st Sess. (Oct. 4, 2001). une/Wawatch.htmArticle
Article published on the Internet ahead of the
32. Map print version:
Pratt B, Flick P, Vynne C, cartographers. See # 18.
Biodiversity hotspots [map]. Washington:
Conservation International; 2000. Optional formats used by NLM in
MEDLINE/PubMed:
33. Dictionary and similar references
Dorland's illustrated medical dictionary. 29th Article with document number in place of
ed. Philadelphia: W.B. Saunders; 2000. traditional pagination:
Filamin; p. 675. Williams JS, Brown SM, Conlin PR. Videos in
clinical medicine. Blood-pressure
Unpublished Material measurement. N Engl J Med. 2009 Jan
34. In press or Forthcoming 29;360(5):e6. PubMed PMID: 19179309.

58 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

 PJP FOR CONTRIBUTORS

Article with a Digital Object Identifier (DOI): American Board of Medical Specialists. c2000
Zhang M, Holman CD, Price SD, Sanfilippo FM, - [cited 2001 Mar 8]. Available from:
Preen DB, Bulsara MK. Comorbidity and repeat http://www.abms.org/newsearch.asp
admission to hospital for adverse drug
reactions in older adults: retrospective cohort Closed database:
study. BMJ. 2009 Jan 7;338:a2752. doi: Jablonski S. Online Multiple Congenital
10.1136/bmj.a2752. PubMed PMID: 19129307; Anomaly/Mental Retardation (MCA/MR)
PubMed Central PMCID: PMC2615549. Syndromes [Internet]. Bethesda (MD): National
Library of Medicine (US); c1999 [updated 2001
Article with unique publisher item identifier Nov 20; cited 2002 Aug 12]. Available from:
(pii) in place of traditional pagination or DOI: http://www.nlm.nih.gov/archive//20061212/m
Tegnell A, Dillner J, Andrae B. Introduction of esh/jablonski/syndrome_title.html
human papillomavirus (HPV) vaccination in
Sweden. Euro Surveill. 2009 Feb 12;14(6). pii: 41. Part of a database on the Internet
19119. PubMed PMID: 19215721. MeSH Browser [Internet]. Bethesda (MD):
National Library of Medicine (US); 2002 - .
37. Monograph on the Internet Meta-analysis [cited 2008 Jul 24]; [about 2 p.].
Foley KM, Gelband H, editors. Improving Available from:
palliative care for cancer [Internet]. http://www.nlm.nih.gov/cgi/mesh/2008/MB_cg
Washington: National Academy Press; 2001 i?mode=&index=16408&view=concept MeSH
[cited 2002 Jul 9]. Available from: Unique ID: D017418.
http://www.nap.edu/books/0309074029/html
/. 42. Blogs
Holt M. The Health Care Blog [Internet]. San
38. Homepage/Web site Francisco: Matthew Holt. 2003 Oct - [cited
Cancer-Pain.org [Internet]. New York: 2009 Feb 13]. Available
Association of Cancer Online Resources, Inc.; from:http://www.thehealthcareblog.com/the_
c2000-01 [updated 2002 May 16; cited 2002 health_care_blog/.
Jul 9]. Available from: http://www.cancer-
pain.org/. KidneyNotes.com [Internet]. New York:
KidneyNotes. c2006 - [cited 2009 Feb 13].
39. Part of a homepage/Web site Available from: http://www.kidneynotes.com/.
American Medical Association [Internet].
Chicago: The Association; c1995-2002 Wall Street Journal. HEALTH BLOG: WSJ's blog
[updated 2001 Aug 23; cited 2002 Aug 12]. on health and the business of health
AMA Office of Group Practice Liaison; [about 2 [Internet]. Hensley S, editor. New York: Dow
screens]. Available from: http://www.ama- Jones & Company, Inc. c2007 - [cited 2009
assn.org/ama/pub/category/1736.html Feb 13]. Available from:
http://blogs.wsj.com/health/.
40. Database on the Internet
Open database: Contribution to a blog:
Who's Certified [Internet]. Evanston (IL): The Mantone J. Head trauma haunts many,

59 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

 PJP FOR CONTRIBUTORS

researchers say. 2008 Jan 29 [cited 2009 Feb Initial Symptoms of the patient, Family &
13]. In: Wall Street Journal. HEALTH BLOG Developmental History, Pre morbid Medical
[Internet]. New York: Dow Jones & Company, History, Initial Examination, Treatment and
Inc. c2008 - . [about 1 screen]. Available from: course of Illness and Discussion.
http://blogs.wsj.com/health/2008/01/29/head & 2) Case Report – Abstract, Introduction
-trauma-haunts-many-researchers-say/. which includes a Literature Review, Case
description in terms of history, Mental Status
Campbell A. Diabetes and alcohol: do the two Exam, Diagnosis and Discussion of the case.
mix? (Part 2). 2008 Jan 28 [cited 2009 Feb 13]. But in either format the ff: must be included:
In: Diabetes Self-Management Blog [Internet]. an unstructured Abstract of a maximum of
New York: Diabetes Self-Management. [2006 100 words, brief Literature Review,
Aug 14] - . 2 p. Available from: description of the case, its treatment/
http://www.diabetesselfmanagement.com/blo management and discussion of analysis
g/Amy_Campbell/Diabetes_and_Alcohol_Do_th (psychodynamics) and at least 10 references.
e_Two_Mix_Part_2 Authors must protect patient anonymity and
disguise their identifying information.
Reider J. Docnotes: Health, Technology,
Family Medicine and other observations Commentaries may be up to a maximum of
[Internet]. [place unknown]: Jacob Reider. 1200 words, and include at least 10
1999 - . CRP again ...; 2004 Apr 2 [cited 2009 references. Authors may be asked for source
Feb 13]; [about 1 screen]. Available from: material to support factual statements in
http://www.docnotes.com/2004/04/crp- opinion pieces.
again.html
Book Reviews may be on books dealing with
More detailed information on how to cite any topic or issue related to or of interest to
references can be found in Citing Medicine. psychiatry, psychology or mental health.
Note Appendix F which covers how citations in Indicate book title, authors/ editors, city
MEDLINE/PubMed differ from the advice where it was published, year published,
inCiting Medicine. publisher, total number of pages and sale
price of book reviewed. References are
PREPARATION OF MANUSCRIPTS FOR CASE optional.
REPORTS, COMMENTARIES, BOOK REVIEWS,
MONOGRAPHS &LETTERS TO THE EDITOR: Letters are published at the editor’s discretion
Case Reports may adapt either of the 2 and should not exceed 500 words, with at
formats: 1) Clinical Case Conference- least 5 references. Letters related to material
Introduction based on Literature Review, published in PJP may be sent to the author
Initial Symptoms of the patient, Family & themselves for possible reply.
Developmental History, Pre morbid Medical
History, Initial Examination, Treatment and REFERENCES:
course of Illness and Discussion. International Committee of Medical Journal
& 2) Case Report – Abstract, Introduction Editors. [home page on the internet].
which includes a Literature Review, Initial Recommendations for the conduct,

60 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884

 PJP FOR CONTRIBUTORS

Reporting, Editing and Publication of Scholarly

Work in Medical Journals [cited 2016 Dec 24]
Available from: http;//www.ICMJE.org.

2.World Medical Association. World Medical

Association Declaration of Helsinki: Ethical
Principles for Medical Research Involving
Human Subjects. JAMA.2013;310 (20):2191-
94.doi.10.1001/jama.20132810

61 · PJP 2023 · Volume 4 (1-2) · ISSN 2980-4884