Professional Documents
Culture Documents
PENYAKIT JIWA
LAINNYA
dr liza (140 366
660)
Indonesia AND
Kognitif
KIRI Pragmati Kanan
ATAS k atas
Logis Konseptual
Kuantitatif Sintesis
Kritis Metaforis
Visual
Analitis Integrative
Factual Whole Brained
Sekuensial Emosional
Terkontrol Indriawi
Konservatif Humanistik
Struktural
Mendetail
Musical
Ekspresif
Kiri Kanan
bawah Intuitif bawah
Instingtif
Regional Functions of the
Human Brain
Frontal lobes
Voluntary movement
Language production (left)
Motor prosody (right)
Comportment
Executive function
Motivation
Temporal lobes
Audition
Language comprehension (left)
Sensory prosody (right)
Memory
Emotion
Parietal lobes
Tactile sensation
Visuospatial function (right)
Reading (left)
Calculation (left)
Occipital lobes
Vision
Visual perception
KELUHAN UTAMA
O. BERKELANJUTAN
1. EPISODIK DGN KEMUNDURAN
PROGRESIF
2. EPISODIK DGN KEMUNDURAN
STABIL
3. EPISODIK BERULANG
4. REMISI TIDAK SEMPURNA
5. REMISI SEMPURNA
8. LAINNYA
9. PERIODE PENGAMATAN KURANG
1 TH
POLA PERJALANAN SKIZOFRENIA
MENURUT DSM IV TR
1. EPISODIK DGN SIMPTOM RESIDUAL
ANTARA EPISODE
2. EPISODIK TANPA SIMPTOM RESIDUAL
ANTARA EPISODE
3. BERKELANJUTAN
4. EPISODIK TUNGGAL DENGAN REMISI
SEBAGIAN
5. EPISODIK TUNGGAL DENGAN REMISI
PENUH
6. POLA TIDAK SPESIFIK ATAU LAINNYA
PROGNOSIS SKIZOFRENIA
CIRI-CIRI PROGNOSIS BAIK
LATE ONSET
ONSET AKUT
MEMPUNYAI FAKTOR PENCETUS YANG
JELAS
MEMILIKI RIWAYAT PRAMORBID YANG
BAIK DALAM SOSIAL, SEKSUAL, DAN
PEKERJAAN
DIJUMPAI SIMPTOM DEPRESI
TELAH MENIKAH
MEMILIKI RIWAYAT KELUARGA DENGAN
GANGUAN MOOD
MEMPUNYAI SISTEM SUPPORT YANG BAIK
PROGNOSIS BURUK
ONSET USIA MUDA
ONSET PERLAHAN-LAHAN DAN TIDAK JELAS
TIDAK ADA FAKTOR PENCETUS
MEMILIKI RIWAYAT PRAMORBID JELEK
DIJUMPAI PERILAKU MENARIK DIRI ATAUR AUTISTIK
BELUM MENIKAH/CERAI
MEMILIKI RIWAYAT KELUARGA SKIZOFRENIA
MEMILIKI SISTEM SUPPORT BURUK
GAMBARAN KLINIS ADALAM SIMPTON
NEGATIF/SIMPTON NEUROLOGI
MEMILIKI RIWAYAT TRAUMA MASA PERINATAL
TIDA ADA REMISI SELAMA 3 TAHUN PENGOBATAN
TERJADINYA BANYAK RELAPS
MEMILIKI RIWAYAT SKIZOFRENIA SEBELUMNYA
Schizophrenia
KAPLAN & SADOCK
EDIT DR LIZA
Schizophrenia
Schizophrenia is a clinical syndrome of variable, but
profoundly disruptive, psychopathology that involves
cognition, emotion, perception, and other aspects of
behavior. The expression of these manifestations
varies across patients and over time, but the effect
of the illness is always severe and is usually long
lasting.
The disorder usually begins before age 25, persists
throughout life, and affects persons of all social
classes. Both patients and their families often suffer
from poor care and social ostracism because of
widespread ignorance about the disorder. Although
schizophrenia is discussed as if it is a single disease,
it probably comprises a group of disorders with
heterogeneous etiologies, and it includes patients
whose clinical presentations, treatment response,
and courses of illness vary.
Clinicians should appreciate that the diagnosis of
Kurt Schneider Criteria for Schizophrenia
First-rank symptoms
– Audible thoughts
– Voices arguing or discussing or both
– Voices commenting
– Somatic passivity experiences
– Thought withdrawal and other experiences of influenced
thought
– Thought broadcasting
– Delusional perceptions
– All other experiences involving volition made affects,
and made impulses
Second-rank symptoms
– Other disorders of perception
– Sudden delusional ideas
– Perplexity
– Depressive and euphoric mood changes
– Feelings of emotional impoverishment
– “…and several others as wellâ€
DSM-IV-TR Diagnostic Criteria for Schizophrenia
A.Characteristic symptoms: Two (or more) of the
following, each present for a significant portion of time
during a 1-month period (or less if successfully treated):
– delusions
– hallucinations
– disorganized speech (e.g., frequent derailment or
incoherence)
– grossly disorganized or catatonic behavior
– negative symptoms, i.e., affective flattening, alogia, or
avolition
Note: Only one Criterion A symptom is required if
delusions are bizarre or hallucinations consist of a voice
keeping up a running commentary on the person's
behavior or thoughts, or two or more voices conversing
with each other.
B.Social/occupational dysfunction: For a significant
portion of the time since the onset of the disturbance,
one or more major areas of functioning such as work,
interpersonal relations, or self-care are markedly below
the level achieved prior to the onset (or when the onset
C. Duration: Continuous signs of the disturbance
persist for at least 6 months. This 6-month period
must include at least 1 month of symptoms (or
less if successfully treated) that meet Criterion A
(i.e., active-phase symptoms) and may include
periods of prodromal or residual symptoms.
During these prodromal or residual periods, the
signs of the disturbance may be manifested by
only negative symptoms or two or more
symptoms listed in Criterion A present in an
attenuated form (e.g., odd beliefs, unusual
perceptual experiences).
D. Schizoaffective and mood disorder exclusion:
Schizoaffective disorder and mood disorder with
psychotic features have been ruled out because
either (1) no major depressive, manic, or mixed
episodes have occurred concurrently with the
active-phase symptoms; or (2) if mood episodes
have occurred during active-phase symptoms,
their total duration has been brief relative to the
duration of the active and residual periods.
E. Substance/general medical condition
exclusion: The disturbance is not due to
the direct physiological effects of a
substance (e.g., a drug of abuse, a
medication) or a general medical
condition.
F. Relationship to a pervasive
developmental disorder: If there is a
history of autistic disorder or another
pervasive developmental disorder, the
additional diagnosis of schizophrenia is
made only if prominent delusions or
hallucinations are also present for at least
a month (or less if successfully treated).
Classification of longitudinal course (can be applied
only after at least 1 year has elapsed since the initial
onset of active-phase symptoms):
Episodic with interepisode residual symptoms
(episodes are defined by the reemergence of
prominent psychotic symptoms); also specify if: with
prominent negative symptoms Episodic with no
interepisode residual symptoms
Continuous (prominent psychotic symptoms are
present throughout the period of observation); also
specify if: with prominent negative symptoms
Single episode in partial remission: also specify
if: with prominent negative symptoms
Single episode in full remission
Other or unspecified pattern(From American
Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders. 4th ed. Text rev.
Washington, DC: American Psychiatric Association;
copyright 2000, with permission.)
DSM-IV-TR Diagnostic Criteria for
Schizophrenia
Sub types
Paranoid type
A type of schizophrenia in which the following criteria
are met:
Preoccupation with one or more delusions or frequent
auditory hallucinations.
None of the following is prominent: disorganized
speech, disorganized or catatonic behavior, or flat or
inappropriate affect.
Disorganized type
A type of schizophrenia in which the following criteria
are met:
All of the following are prominent:
– disorganized speech
– disorganized behavior
– flat or inappropriate affect
The criteria are not met for catatonic type.
Catatonic type
A type of schizophrenia in which the clinical
picture is dominated by at least two of the
following:
motoric immobility as evidenced by catalepsy
(including waxy flexibility) or stupor
excessive motor activity (that is apparently
purposeless and not influenced by external
stimuli)
extreme negativism (an apparently motiveless
resistance to all instructions or maintenance of
a rigid posture against attempts to be moved)
or mutism
peculiarities of voluntary movement as
evidenced by posturing (voluntary assumption
Undifferentiated type
A type of schizophrenia in which symptoms that meet
Criterion A are present, but the criteria are not met for
the paranoid, disorganized, or catatonic type.
Residual type
Homicide
Despite the sensational attention that the news
media provides when a patient with
schizophrenia murders someone, the available
data indicate that these patients are no more
likely to commit homicide than is a member of
the general population. When a patient with
schizophrenia does commit homicide, it may be
for unpredictable or bizarre reasons based on
hallucinations or delusions. Possible predictors
of homicidal activity are a history of previous
violence, dangerous behavior while
hospitalized, and hallucinations or delusions
A schizophrenic man who had been going
home on weekends for many months was
told by his sister that she would not ask
for permission any more to take him out
of the hospital if he would not do his part
with the housework in the future, for
instance, help with the dishes. On the
next weekend visit, the patient killed his
sister and mother. He had shown no signs
of disturbance whatsoever during the
preceding week, had been sleeping well,
and had been attending occupational
therapy classes as usual.
A 19-year-old boy who had been
discharged from a mental hospital, in what
appeared to be a residual state of chronic
schizophrenia of the undifferentiated type,
stabbed his father to death when the
latter, during a state of intoxication, told
the patient that he was too much of a
bother around the house and that he
might as well return to the hospital.
Another schizophrenic, whose condition
had not yet been diagnosed, complained
to a general practitioner about various
physical ailments. When the physician
finally told him that he should not come
anymore because there was nothing else
he could do for him, the patient quickly
DSM-IV-TR Diagnostic Criteria for
Schizophreniform Disorder
Criteria A, D, and E of schizophrenia are met.
An episode of the disorder (including prodromal,
active, and residual phases) lasts at least 1 month
but less than 6 months. (When the diagnosis must be
made without waiting for recovery, it should be
qualified as “provisional.â€)
Specify if:
Without good prognostic features With good
prognostic features: as evidenced by two (or
more) of the following:
onset of prominent psychotic symptoms within 4
weeks of the first noticeable change in usual
behavior or functioning
confusion or perplexity at the height of the psychotic
episode
good premorbid social and occupational functioning
absence of blunted or flat affect
Ms. V was a 30-year-old white woman from a working-class family.
She was born prematurely and as a toddler had a seizure disorder
that was treated with phenobarbital (Luminal, Solfoton) for 1 year.
She did well in school, but dropped out in the 12th grade, obtained a
General Educational Development (GED) diploma, and began
working at 18 years of age.
She described her adolescence as a time when she was happy,
outgoing, and had several friends. She married at 21 years of age
and had two children, but 9 months before her initial hospitalization,
she and her husband separated.
Ms. V began working in a local factory, and she and her children
moved in with her mother. About 6 weeks before her initial
admission, Ms. V started feeling that drug dealers and gangsters
were out to hurt her and that people were poisoning her food. She
also did not let her children eat, fearing they would die from food
poisoning.
She was admitted to the hospital for 2 weeks but did not receive any
medications at that time. Three weeks after discharge, she was
readmitted with the same symptoms and also experienced thought
broadcasting, thought insertion, and olfactory hallucinations.
She was treated with haloperidol (Haldol) and was discharged after
1 month. She later moved to Florida with her mother and children,
worked full time, and remained free of symptoms without treatment
for 9 years. At that time, she again became psychotic, but after
treatment with olanzapine (Zyprexa) for 1 month, she recovered
fully and resumed her usual social and occupational functioning.
Differential Diagnosis
It is important to first differentiate
schizophreniform disorder from psychoses that
can arise from medical conditions. This is
accomplished by taking a detailed history and
physical examination and, when indicated,
performing laboratory tests or imaging studies.
A detailed history of medication use, including
over-the-counter medications and herbal
products, is essential because many
therapeutic agents can also produce an acute
psychosis. Although it is not always possible to
distinguish substance-induced psychosis from
other psychotic disorders cross-sectionally, a
rapid onset of psychotic symptoms in a patient
with a significant substance history should raise
the suspicion of a substance-induced psychosis.
A detailed substance use history and
toxicological screen are also important for
The duration of psychotic symptoms is
one of the factors that distinguish
schizophreniform disorder from other
syndromes. Schizophrenia is diagnosed if
the duration of the prodromal, active, and
residual phases lasts for more than 6
months, whereas symptoms that occur
for less than 1 month indicate a brief
psychotic disorder. In DSM-IV-TR, a
diagnosis of brief psychotic disorder does
not require that a major stressor be
present.
To distinguish mood disorders with
psychotic features from schizophreniform
disorder is sometimes difficult. Further
more, schizophreniform disorder and
schizophrenia can be highly comorbid with
mood and anxiety disorders. Additional
confounds are that mood symptoms, such
as loss of interest and pleasure, may be
difficult to distinguish from negative
symptoms, avolition, and anhedonia.
Some mood symptoms may also be
present during the early course of
schizophrenia. A thorough longitudinal
history is important in elucidating the
diagnosis because the presence of
psychotic symptoms exclusively during
periods of mood disturbance is an
indication of a primary mood disorder.
Course and Prognosis
The course of schizophreniform disorder, for the
most part, is defined in the criteria. It is a
psychotic illness lasting more than 1 month and
less than 6 months. The real issue is what
happens to persons with this illness over time.
Most estimates of progression to schizophrenia
range between 60 and 80 percent. What happens
to the other 20 to 40 percent is currently not
known. Some will have a second or third episode
during which they will deteriorate into a more
chronic condition of schizophrenia. A few,
however, may have only this single episode and
then continue on with their lives, which is clearly
the outcome desired by all clinicians and family
members, although it is probably a rare
occurrence and should not be held out as likely.
ICD-10 Diagnostic Guidelines for
Acute Schizophrenia-Like Psychotic
Disorder
The onset of psychotic symptoms must be
acute (2 weeks or less from a
nonpsychotic to a clearly psychotic state).
Symptoms that fulfill the criteria of
schizophrenia must have been present for
the majority of time.
The criteria for acute polymorphic
psychotic disorder are not fulfilled.
If the psychotic symptoms last for more
than 1 month, then the diagnosis should
be changed to schizophrenia.
Schizoaffective Disorder
As the term implies, schizoaffective disorder
has features of both schizophrenia and
affective disorders (now called mood
disorders). In current diagnostic systems,
patients can receive the diagnosis of
schizoaffective disorder if they fit into one of
the following six categories:
(1) patients with schizophrenia who have
mood symptoms;
(2) patients with mood disorder who have
symptoms of schizophrenia;
(3) patients with both mood disorder and
schizophrenia
(4) patients with a third psychosis unrelated to
schizophrenia and mood disorder;
(5) patients whose disorder is on a continuum
(6) patients with some combination of the
above. The revised fourth edition of the
Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV-TR) incorporated the
stricter time frame of 1 month's duration of
schizophrenia symptoms and required an
uninterrupted period of illness during which
at some time, either there is a Major
Depressive Episode, a Manic Episode, or a
Mixed Episode concurrent with symptoms
that meet Criterion A for Schizophrenia.
DSM-IV-TR also elaborated more on the
criterion of duration of the mood symptoms
relative to the psychotic symptoms. In the
tenth revision of International Statistical
Classification of Diseases and Related
Health Problems (ICD-10), schizoaffective
disorder is a distinct entity and can be
applied to patients who have co-occurring
mood symptoms and schizophrenic-like
mood-incongruent psychosis.
DSM-IV-TR Diagnostic Criteria for Schizoaffective
Disorder