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KIRI ATAS Logis Kuantitatif Kritis Analitis Factual
Kognitif Pragmati k
Konseptual Sintesis Metaforis Visual Integrative
Realistis Common Sense
Sekuensial Terkontrol Konservatif Struktural Mendetail
Emosional Indriawi Humanistik Musical Ekspresif Intuitif Instingtif Kanan bawah
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
FISIK APAKAH MURNI/ FISIK GANDA
KELUHAN BERKAITA PSIKOSOMATIK DENGAN MASALAH KELUHAN FISIK ALAM PERASAAN BERKAITAN PIKIRAN DENGAN PSIKIS PRILAKU 5. JANTUNG DEBAR F. PSIKOSIS 6. DARAH TINGGI G.ANXIETAS 7. ULU HATI SAKIT, H. DEPRESI 8. DIARE I. ZAT 9. GATAL/EKSIM J. RETARD MENT 10.ASMA K. EPILEPSI 11.KEPUTIHAN 12.BANYAK KERINGAT L. GANGGUAN PERK ANAK DAN REMAJA 13.GANGGUAN HAID
PERTANYAAN AKTIF BILA ADA KEL PSIKOSOMATIK, MENTAL EMOSIONAL, DAN G FISIK GANDA DENGAN G. MENTAL EMOSI
DISTRESS (DIRI, LINGK, DAN ATAU KELUARGA) ADA GANGGUAN FUNGSI PEKERJAAN/AKADEMIK, SOSIAL DAN SEHARI HARI KHUSUS ANAK ADA GANGGUAN PERKEMBANGAN, MASIH NGOMPOL, TERLALU NAKAL, GANGGUAN MAKAN, KESULITAN BELAJAR, TAK MAU SEKOLAH, SERING MELARIKAN DIRI
BILA DISERTAI GANGGGUAN ORGANIK TAPI PERTANYAAN DIATAS TIDAK ADA DISTRES
(0801) FO DELIRIUM (0801) FO G. PSIKOSOMATIK (0802) F5 G. PENGGUNAAN ZAT (0805) F1 G. RETARDASI MENTAL (0803) F 7 EPILEPSI (0901) G 38
PERTANYAAN AKTIF YA TANPA KELAINAN ORGANIK
PSIKOSOMATIK (0801) F2 G. DEPRESI (0802) F3 G, CEMAS (0802) F4 G. KESEHATAN JIWA ANAK DAN REMAJA (0804) F8 F9 G. KEPRIBADIAN (0805) F5 F6
0801 GANGGUAN PSIKOTIK
MENTAL ORGANIK SKIZOFRENIA DAN GANGGUAN WAHAM GANGGUAN SUASANA PERASAAN DALAM BENTUK PSIKOTIK
WAHAM =KEYAKINAN MENETAP YANG TIDAK SESUAI DENGAN KENYATAAN DAN SELALU DIPERTAHANKAN HALUSINASI = PERSEPSI PANCAINDERA TANPA SUMBER RANGSANGAN SENSORIK EKSTERNAL SEPERTI MENDENGAR BISIKAN, MELIHAT BAYANGAN INKOHERENSI = PEMBICARAAN KACAU/ TULISAN YANG TIDAK DIMENGERTI KATATONIA = GANGGUAN PSIKOMOTOR STUPOR (TIDAK BERGERAK). MUTISME (TAK BICARA), FUROR (GADUH GELISAH), NEGATIVISME (MENENTANG). POSITIONING (BERTAHAN DALAM POSISI TERTENTU). RIGIDITAS (KEKAKUAN TUBUH). FLEKSIBILITAS LILIN (POSISI DAPAT DIATUR OLEH PEMERIKSA SEOLAH BERBENTUK LILIN), OTOMATISME PERINTAH (PERINTAH DILAKSANAKAN SECARA OTOMATIS TANPA BERFIKIR LAGI)
TANDA/ GEJALA ORGANIK
ORGANIK SPESIFIK YANG DIDUGA ADA KAITAN DENGAN KEJIWAAN TRAUMA, TOKSIN, PENYAKIT FISIK BERKAITAN DENGAN SSP SEPERTI PANAS TERLALU TINGGI, PENYAKIT FISIK YANG MENIMBULKAN GANGGUAN METABOLISME PADA OTAK PENURUNAN KESADARAN PATOLOGIK, APATIS, APATIS, SOMNOLEN, SOPOR, KOMA, DELIRIUM.
GANGGUAN FUNGSI INTELEK/KOGNITIF
KECERDASAN MENURUN : BERKURANGNYA KEMAMPUAN UNTUK MENGGUNAKAN HAL HAL YANG TELAH DIPELAJARI DISORIENTASI : GANGGUAN PEMAHAMAN TERHADAP LINGKUNGAN (DISORIENTASI WAKTU, TEMPAT, DAN ORANG) GANGGUAN DAYA INGAT: LUPA AKAN HAL-HAL YANG TELAH TERJADI
(F0) KESADARAN SENSORIUM BAIK, GANGGUAN DAYA INGAT, USIA > 60 TH (DEMENSIA PRESENILIS) KADANG2 DISERTAI DISORIENTASI DELIRIUM (F0) KESADARAN BERKABUT, GELISAH, BISA DISERTAI HALUSINASI VISUAL , DISORIENTASI SKIZOFRENIA DAN GANGGUAN WAHAM, GEJALA PSIKOTIK, BERLANGSUNG LEBIH DARI 1 BULAN, TANPA GANGGUAN KOGNITIF GANGGUAN SUASANA PERASAAN TERUTAMA GEJALA AFEKTIF SEPERTI EPISODE DEPRESI ATAU EPISODE MANIK
0802 GANGGUAN NEUROTIK
NEUROTIK DENGAN AFEK CEMAS, GANGGUAN CEMAS, FOBIA, OBSESI KOMPULSI, PANIK, GANGGUAN STRES PASCA TRAUMA (F4) GANGGUAN NEUROTIK DENGAN AFEK DEPRESI, GANGGUAN DEPRESI (F3) GANGGUAN STRESS PASCE TRAUMA (F4) GANGGUAN NEUROTIK DENGAN KELUHAN FISIK GANGGUAN PSIKOSOMATIK (F5) , GANGGUAN SOMATOFORM (F4)
GANGGUAN NEUROTIK (DENGAN AFEK CEMAS) * AFEK/MOOD: SUASANA ALAM PERASAAN YANG RELATIF MENETAP, YANG SERING MEMPENGARUHI PERILAKU DAN PERSEPSI INDIVIDU AKAN DUNIA LUAR SEPERTI CEMAS DAN DEPRESI * CEMAS : RASA KAWATIR YANG BERLEBIHAN DISERTAI DENGAN KETEGANGAN MOTORIK (TEKANAN DARAH MENINGKAT, PUSING2, PEGAL2) HIPERAKTIFITAS AUTONOM, (KERINGAT DINGIN, BERDEBAR, SESAK NAFAS, SAKIT PERUT) DENGAN/TANPA DIDAHULUI STRESOR YANG BERMAKNA)
:KETAKUTAN IRASIONAL YANG MENETAP TERHADAP SUATU OBJEK/SITUASI 1.FOBIA SOSIAL : TAKUT DIPERHATIKAN, SALAH TINDAK 2. AGORAFOBIA: FOBIA TERHADAP KERAMAIAN DAN KESENDIRIAN 3. KLAUSTROFOBIA: FOBIA TERHADAP RUANG TERTUTUP 4. AKROFOBIA: FOBIA TERHADAP KETINGGIAN 5. AICHMOFOBIA : FOBIA TERHADAP BENDA TAJAM
PIKIRAN BERULANG YANG TIDAK BISA DIHINDARKAN KOMFULSI: PERBUATAN BERULANG YANG TIDAK BISA DIHINDARKAN PANIK: SERANGAN ANXIETAS BERAT DALAM KEADAAN DIMANA TIDAK ADA BAHAYA GANGGUAN STRESS PASCA TRAUMA: ANXIETAS YANG TERJADI DALAM KURUN WAKTU 6 BULAN SETELAH SUATU KEADAAN TRAUMATIK YANG SANGAT BERAT
DEPRESI : RASA SEDIH YANG BERLEBIHAN DAN BERKEPANJANGAN , DISERTAI DENGAN GANGGUAN FUNGSI PEKERJAAN, FUNGSI SOSIAL DAN PERAWATAN DIRI GEJALA DEPRESI : RASA SEDIH, MURUNG, PUTUS ASA, RENDAH DIRI KEHILANGAN GAIRAH KERJA, BELAJAR, GAIRAH SEX, LESU, AKTIFITAS BERKURANG GANGGUAN MAKAN (TIDAK NAFSU MAKAN/BERLEBIHAN, GANGUAN TIDUR (SULIT/ TERLALU BANYAK TIDUR) MENYENDIRI, TAK SUKA BERGAUL, KURANG KOMUNIKASI
GANGGUAN NEUROTIK DENGAN AFEK DEPRESI
GANGGUAN NEUROTIK dgn kel fisik
fisik: semua keluhan fisik dengan /tanpa kelainan organik yang melatarbelakangi oleh faktor psikologik (berupa afek anxietas atau depresi) Bentuk keluhan fisik= cefalgia, hipertensi, asma bronkial, gastritis, kolitis kronik, rematik, dermatitis Faktor psikososial: masalah keluarga, lingkungan sosial, pendidikan, pekerjaan, perumahan, ekonomi, politik, hukum dan lain2
RETARDASI MENTAL (F7) 0803
KECERDASAN IQ <70 KEMAMPUAN ADAPTASI KURANG DIDAPATKAN PADA USIA <18 TH PEMBAGIAN RM RINGAN IQ 50-69 RM SEDANG IQ 35-49 RM BERAT IQ 20-34 RM SANGAT BERAT IQ <20 CONTOH UMUR 8 TH, KECERDASAR 4 TH, IQ = 4/8 X 100 = 50
0804 GANGGUAN KESEHATAN JIWA PADA BAYI ANAK DAN REMAJA GANGGUAN PERKEMBANGAN BERBICARA, BERBAHASA, BELAJAR, MOTORIK (F8) GANGGUAN PERKEMBANGAN PERVASIF (F8) GANGGUAN HIPERKINETIK (F9) GANGGUAN TINGKAH LAKU (F9) GANGGUAN EMOSIONAL (F9) GANGGUAN FUNGSI SOSIAL (F9) GANGGUAN “TIC” F9
0901 EPILEPSI 640
= KESADARAN MENURUN/BERUBAH AURA (SENSASI SBELM TIMBULNYA SERANGAN): BISA ADA ATAU TIDAK ADA KEJANG UMUM, FOKAL, ATAU TIDAK ADA KEJANG SERANGAN BERULANG DAN EPISODIK GEJALA : FISIK / PSIKIS TERMASUK GRANDMAL, PETITMAL, PSIKOMOTOR, FOKAL MOTOR EPILEPSI EKIVALEN MISAL SAKIT PERUT PERIODIK, KEJANG DEMAM PADA
MEDIKAMENTOSA ANTI PSIKOTIK/NEUROLEPTIKA 1. GOL POTENSI RENDAH DENGAN DOSIS EFEKTIF > 100 MG/HR) DAN MEMPUNYAI EFEK SEDASI KUAT MISALNYA - GOL TIPIKAL: CHLORPROMASONE 100 THIORIDAZINE 100 -GOL ATIPIKAL : QUETIAPINE 100 CLOZAPINE 100
DENGAN POTENSI TINGGI (DGN DOSIS EFEKTIF <100 MG/HR) DAN MEMPUNYAI EFEK SEDASI RINGAN MISALNYA - TIPIKAL : 1. FLUFENAZINE 5 MG 2. TRIFLUOPERAZINE 5 MG 3. PERPHENAZINE 4 MG 4. HALOPERIDOL 2 MG - ATIPIKAL 1. RISPERIDONE 1 MG 2. OLANZAPINE 5 MG
CHLORPROMAZINE (GENERIK 25 MG, 100 MG PERTAB) 150-1800 MG/R (3X50-600MG) DOSIS AWAL 25 MG X 3/HR ATAY 75 MG MALAM, ANAK SKIZP-AUTISME, 1-5 TH, 500 MCG/KG SETIAP 4-6 JAM.(MAKS 40 MG/HR), 6-12 TH, 1/3-1/2 DWS. GEGUKAN YANG SULIT DIOBATI 25 MG X 3 ** CEPEZET (TABCO 100 MG, AMP 50MG/2ML) DOSIS ADULT 10-20 MG EVERY 4-6 HOURS, PSiCHOSIS 200-800 MG DAILY, CHILDREN 0,5 MG/KGBB EVERY 4-6 HRS **MEPROSETIL (FILOTAB 25 MG, 100 MG) **PROMACTIL (FILM CO TAB 100 MG)
DOSIS THERAPEUTIK ANTI PSIKOTIK
KLORPROMAZIN HINDARI KONTAKHIDROKLORIDA LANGSUNG
PERINGATAN: PENYAKIT KARDIOVASKULAR, DAN SEREBROVASKULAR, PENYAKIT PERNAFASAN, PARKINSONISM, EPILEPSI, INFEKSI AKUT, HAMIL, MENYUSUI, GANGGUAN GINJAL, HATI, RIWAYAT KUNING LEUKOPENIA, HIPOTIROIDISME, HIPERTROPI PROSTAT, HATI HATI PADA PS USILA, HINDARI PEMUTUSAN OBAT MENDADAK, SETELAH INJEKSI IM PS HARIS TETAP TIDURAN 30 MNT KONTRAINDIKASI: KOMA KRN DEPRESAN SSP, DEPRESI SUMSUM TULANG, HINDARI PADA FEIKROMOSITOMA, GANGGUAN HATI DAN GINJAL BERAT EFEK SAMPINGl GEJALA EKSTRAPIRAMIDAL, TARDIVE DYSKINESIA, HIPOTERMIA, KADANG KADANG PANAS, MENGANTUK, APATIS, PUCAT, BERMIMPI BURUK, INSOMNIA, DEPRESI, AGITASI, PERUBAHAN EEG, KEJANG PADA GEJALA ANTI MUSKARINIK YANG TERDIRI ATAS : MULUT KERING, HIDUNG TERSUMBAT, KONSTIPASI, KESULITAN BUANG AIR KECIL, PANDANGAN KABUR, GEJALA KARDIOVASKULAR, MELIPUTI HIPOTENSI, TAKIKARDIA, ARITMIA, TERJADI PERUBAHAN EKG, PENGARUH ENDOKRIN SEPERTI GG MENSTRUASI, GALAKTORE, GINEKOMASTIA, IMPOTENSI, PERUBAHAN BB, TERJADI REAKSI SENSITIVITAS, AGRANULOSITOSIS, LEUKOPENIA, LEUKOSITOSIS, ANEMIA HEMOLITIK, FOTOSINTESIS, SENSITISASI KONTAK, RUAM, SAKIT KUNING, PERUBAHAN FUNGSI HATI, SINDROM NEUROLEPTIK
(2X50-400MG) **MELLERIL @ TAB (50 MG), 100 MG D
DOSIS MELLERIL ANXIOLITIC ANTIDEPRESAN ADULT 10-75 MG DAILY, CHILDREN ADJUCTIVE THERAPY IN CONCDIFFICULTIES, BEHAVIOUR DISORDERS, HIPERACTIVITY, AGGRESSIVENESS, SLEEP DISTURBANCES, 0,5 – 2 MG/KGB DAILY ALCHOHOLIC PATIENTS DURING WITHDRAWAL 100 -200 MG DAILY SEVERE NEUROSIS 25-15- MG DAILY MAX 800 MG DAILY CHILDREN CHILDHOOD SCHIZOFRENIA, SEVERE BEHAVIOURAL DISORDERS IN MENTAL RETARDATION AND PSYCHOPATHY 1-4 MG/KG DAILY IN DIVIDED DOSES
HALOPERIDOL 1,5 MG-30 MG/HR (3X0,5-10MG)
HALDOL 2 MG, 5 MG DOSIS NERVOUSNESS, ANXIETY STATES, TICS, STUTTER GI UPSET 0,5 MG 2 TIMES DAILY Ederly 0.5-2 mg 2-3 times daily
MANIA , ACUTE AND CHRONIC SCHIZOFRENIA, PARANOIA, BEHAVIOR & CHARACTER DISORDER IN CHILD MODERATE 0,5 – 2 MG 2-3 TIMES DAILY. Severe 3-5 mg 2-3 times daily
DORES (1,5 MG, TAB), CAP 5 MG
Children 3-12 yr 0.05-0.15 mg/kgbb in divided dose Chronic schizofrenia adult&child >12 y initialy 6-15 mg in 2-3 divided dosis Eat with meals to minimise gi imtation
Govotil tab 2 mg, tab 5 mg Haldol decanoas ampul 50 mg/ml (1 ml),
acute & chronic schizophrenia & other psychotic condition, alleviates affective symptoms associated with schizophrenia D: 1 st day 2 mg daily un 1-2 divided doses 2nd day 4 mg daily 1-2 divided doses 3rd day 6 mg daily in 102 divided doses General doses 4-8 mg daily Eiderly renal, hepatic disease initial 0,5 mg twice daily doses maybe increased
INDIKASI : SKIZOFRENIA AKUT & KRONIK PERINGATAN: PENYAKIT KARDIOVASKULAR BILA TERJADI HIPOTENSI DOSIS DITURUNKAN, INSUFISIENSI GINJAL, HATI, USIA LANJUT PARKINSONISME, EPILEPSI, MENGEMUDI, MENJALANKAN MESIN, HAMIL, MENYUSUI, PANTAU TANDA TARDIVE DYSKINESIA EFEK SAMPING : INSOMNIA, AGITASI, ANSIETAS, NYERI KEPALA, PUSING, SOMNOLEN, LESU, DISPEPSIA, MUAL, NYERI ABDOMEN, GEJALA EKSTRAPIRAMIDAL RISPERDAL 1,2,3 MG
ABILIFY @ I : SCHIZOFRENIA D: 10 OR 15 MG ONCE DAILY SP: REDUCE OR DISCONTINUE DOSE IF SIGN OR SYMPTOMS OF TARDIVE DYSKENESIA, NEUROLEPTIC MALIGNANT SYNDROME APPEAR, HISTORY OF SEIZURE, PREGNANCY & LACTATION, MAY IMPAIR ABILITY TO DRIVE OR OPERATE MACHINERY AR: HEADACHE, NAUSEA, VOMITING, CONSTIPATION, ANXIETY, INSOMNIA, LIGHTHEADEDNESS, SOMNOLENCE,
TAB 25 MG, 100 MG CLOZARIL TAB 25 MG, 100 MG LUFTEN DOSIS : 12,5 MG ONCE OR TWICE DAILY ON THE 1 ST DAY, FOLLOWED BY STEPWISE INCREASE W/DAILY INCREMENTS DOSES MAX 600 MG/DAY EXCEPTIONS 900 MG
ZYPREZA TAB 5 MG, 10 MG, VIAL 10 MG DOSIS: TAB SCHIZOPHRENIA & RELATED DISORDERS STARTING DOSE 10 MG/DAY MANIC EPISODES STARTING DOSE 15 MG/DAY AS A SINGLE DOSE IN MONOTHERAPY OR 10 MG/DAY IN COMBINATION WITH LITHIUM OR VALPROATE PREVENTING RECURRENCE IN BIPOLAR DISORDER 10 MG.DAY DURING TREATMENT FOR BOTH SCHIZOPHRENIA & MANIC EPISODES DAILY DOSAGE SUBSEQUENTLY BE ADJUSTED ACCORDING TO CLINICAL RESPONSE WITHIN THE RANGE 0F 5-20 MG/DAY . VIAL 10 MG AS
DOSI S MAKS
CLOZA 25-50 PINE OLAN ZAPIN E
QUE TIAPI DINE
SKISOFRENIA REFRAKTER , EPS RENDAH DITOLERANSI DENGAN BAIK, EFEKTIF UNTUK MANIA AKUT DITOLERANSI DENGAN BAIK RESIKO EPS RENDAH
AGRANULUS ITOSIS, BB NAIK, KEJANG BERAT BADAN NAIK TITRASI DOSIS SEDASI
15-20 1 X/HR
400600 2–3 X/HR
RISPE 1-2 RIDO NE
ZIPRA SIDON E 40-80
DITOLERANSI DGN BAIK WELL DEFINED DOSE RANGE
DOSIS TERGANTUN G EPS
DITOLERANSI DENGAN BAIK BB TIDAK NAIK’ADA INJ
QT PROLONGE , BERSAMA MAKANAN
DOSIS/ HR 5-20 MG (2X/HR) 5-30 MG (2x/HR)
WAKTU PARUH JAM 12-36
HALO PERI DOL TRI FLUO PERA ZINE CHLOR PROMAZIN E
EPS +++, SEDASI +, OTONOM + EPS +++, SEDASI ++. OTONOM +
200-600 MG (2X/HR) 2-20 MG (2-3x/HR)
100 MG 2 MG
SEDASI +++, OTONOM +++, EPS + EPS +++, SEDASI + OTONOM + EPS +++, SEDASI +, OTONOM + -
THIORIDAZI 200NE 600MG SULPIRIDE 2X/HR 400-2400 (2x)
GAMBA RAN NEURO TRANS MITER O/OBAT
OBAT TERSEBUT MEMBERI GAMBARAN GEJALA SEPERTI SKIZOFRENIA
AMFETAMIN MENYEBABKAN PELEPASAN DAN MENCEGAH REUPTAKE (PENGAMBILAN KEMBALI DARI DOPAMIN LSD, ANTAGONIS PARSIAL AGONIS DI RESEPTOR 5HT2A DAN 5HT2C, PELEPASAN NMDA DAN PENCEGAHAN REUPTAKE SEROTONIN DARI SINAP KETAMIN DAN PCP ANTAGONIS RESEPTOR NMDA
EKSITASI, PENINGKATAN INSOMNIA, HALUSINASI, KEWASPADAAN, HOSTILITAS, KETERGANTUNGAN EKSITASI, INSOMNIA, EUFORIA, HALUSINASI VISUAL, PARANOIA, KETERGANTUNGAN
GEJALA POSITIF, HALUSINASI, TERUTAMA PENGLIHATAN, PERABAAN, WAHAM KEJAR GEJALA POSITIF DISFORIK, PERUBAHAN MOOD, IDEAS OF REFERENCE, AFEK YANG TIDAK SERASI, CONCRETE THINGKING GEJALA POSITIF DAN NEGATIF: NEGATIVISME, APATIS, DEFISIT KOGNITIF
ANESTESI, DISTORSI DARI BODY IMAGE, KETERGANTUNGAN, EKSITASI, HALUSINASI
Indikasi : parkinsonisme, gangguan ekstrapiramidal karena obat kecuali tardive dyskinesia Peringatan, penyakit kardiovaskular, hati , ginjal, hindari pemutusan obat mendadak, usila Kontra indikasi: retensi urin, glukoma (sdt sempit), obstruksi sal cerna Efek samping, mulut kering, gangguan pencernaan, pusing , penglihatan kabur, retensi urin, takikardia, hipersensitiv, gugup, dosis tinggi pada pasien yang peka, bingung, eksitasi, gangguan jiwa Dosis 1 mg/hr dinaikan bertahap, dosis pemeliharaan 5-15 mg/hr terbagi 3-4 kali . Usua lanjut dosis dibawah kisaran dosis Generik tryhexyphenidil tab 2 mg, 5 mg Arkine kaptab 2 mg, artane tab 2 mg, parkinal tab 2 mg
I: PEMAKAIAN JANGKA PENDEK PD ANSIETAS, ATAU INSOMNIA, TAMBAHAN PADA PUTUS ALKOHOL AKUT, STATUS EPILEPTIKUS, KEJANG DEMAM SPASME OTOT PERINGATAN: DAPAT MENGGANGGU KEMAPUAN MENGEMUDI. HAMIL, MENYUSUI, USILA LANJUT, PENYAKIT HATI, GINJAL, PENYAKIT PERNAFASAN, KELEMAHAN OTOT, RIWY KEPRIBADIAN NYATA, KURANGI DOSIS, PADA USIA LANJUT, DEBIL NYATA, HINDARI PEMAKAIAN JANGKA PANJANG, PERINGATAN KHUSUS UNTUK INJEKSI KONTRAINDIKASI: DEPRESI, PERNAFASAN, GANGGUAN HATI BERAT, MIASTENIA GRAVIS, INSUFISIENSI PULMONER AKUT, KONDISI FOBIA, OBSESI, PSIKOSIS KRONIK, GLUKOMA SDT SEMPIT AKUT, SERANGAN ASMA AKUT, TRIMESTER PERTAMA KEHAMILAN, BAYI PREMATUR, TIDAK BOLEH DIGUNAKAN SENDIRIAN PADA DEPRESI ATAU ANSIETAS DENGAN DEPRESI EFEK SAMPING: NGANTUK, KELEMAHAN OTOT, ATAKSIA, REAKSI PARADOKSAL DALAM AGRESI, GANGGUAN MENTAL, AMNESIA, KETERGANTUNGAN, DEPRESI NAFAS, KEPALA LEBIH RINGAN HARI BERIKUTNYA, BINGUNG. KADANG TERJADI NYERI KEPALA, VERTIGO, HIPOTENSI, PERUBAHAN SALIVA, GANGGUAN SAL CERNA, RUAM, GANGGUAN PENGLIHATAN, PERUBAHAN LIBIDO, RETENSI URIN, DILAPORKAN KELAINAN DARAH DAN SAKIT KUNING PADA INJEKSI IV TERJADI NYERI , TROMBOFLEBITIS, JARANG APNEU/HIPOTENSI
DOSIS : ORAL ANSIETAS 2 MG 3 X/HR, DINAIKAN KALAU PERLU SAMPAI 15-30 MG/HR DALAM DOSIS TERBAGI UNTUK USILA ATAU DEBIL DOSIS 1/2NYA INSOMNIA DISERTAI ANSIETAS 5-15 MG SBLM TIDUR INJEKSI IM. INJEKSI IV LAMBAT KEDALAM VENA YANG BESAR DENGAN KECEPATAN TIDAK LEBIH DARI 5 MG/MNT) UNTUK ANSIETAS AKUT BERAT, PENGENDARILIAN SERANGAN PANIK AKUT, DAN PUTUS ALKOHOL AKUT : 10 MG DIULANGI BILA PERLU,SETELAH TIDAK KURANG 4 JAM DIAZEPAM GENERIK 2 MG, 5 MG TAB STESOLID INJ 10 MG/2 ML, ENEMA 5 MG.2,5 ML, 10 MG/2,5 ML. SIRUP 2 MG/5 ML. TAB 2 MG, TAB 5 MG VALIUM INJ 5 MG/ML. TAB 2 MG, TAB 5 MG VALISANBE 2 MG , 5 MG TAB
EMIL KRAEPELIN (1856-1926)= DEMENSIA PREKOKS, (DEMENSIA PADA USIA DINI), DITANDAI DENGAN PROSES KOGNITIF YANG MAKIN LAMA MAKIN MEMBURUK DAN DISERTAI DENGAN GEJALA KLINIS BERUPA HALUSINASI EUGEN BLEULER (1957-1939) SKIZOFRENIA TERJADINYA PERPECAHAN ANTARA PIKIRAN, EMOSI DAN PERILAKU 4 A: ASOSIASI, AFEK TERGANGGU, AUTISME, AMBIVALENSI, DITAMBAH WAHAM DAN HALUSINASI GABRIEL LANGFELDT- MEMBAGI GJL PSIKOTIK ADA 2 KELOMPOK, TRUE SCHIZOPHRENIA ( DEPERSONALISASI, AUTISME, EMOSI TUMPUL, DAN
KRITERIA DIAGNOSIS MENURUT LANGFELDT 1. KRITERIA SIMPTOM, MERUPAKAN PETUNJUK PENTING UNTUK MENDIAGNOSIS SUATU SKIZOFRENIA, DAPAT DIGUNAKAN BILA TIDAK DITEMUKAN ADANYA TANDA2 BERUPA GANGGUAN KOGNITIF, INFEKSI, INTOKSIKASI, MELIPUTI 1. PERUBAHAN KEPRIBADIAN, BERUPA EMOSI YANG TUMPUL, DIIKUTI DENGAN HILANGNYA INISIATIF, DAN PERUBAHAN PERILAKU SEHINGGA PENDERITA TERLIHAT ANEH 2. TIPE KATATONIK , KEGELISAHAN & STUPOR 3. PSIKOSIS PARANOID DITANDAI GEJALA DEPERSONALISASI DAN DEREALISASI ATAU WAHAM PRIMER, 4. HALUSINASI KRONIS
dari populasi dunia (0,85%) Insidens 1: 10.000 orang pertahun Prevalensi berdasar jenis kelamin, budaya sama. Wanita gej lebih ringan , lebih sedikit rawat inap. Lebih baik dikomunitas dari pada laki2 Onset pada laki2 terjadi lebih awal drpd w Onset puncak laki2 umur 15-25 th, wanita 25 -35 th, jarang pada usia<10/>50 th.
Individu yang didiagnosis dengan skizofrenia 60-70 % tidak pernah menikah 25-50% berusaha bunuh diri, 10 % berhasil Faktor resiko kasuk suicide, dejala depresif, usia muda, tingkat fungsi pramorbid yang tinggi, halusinasi dengar, usaha sebelumnya, tinggal sendiri, perbaikan setelah relaps, ketergantungan pada rumah sakit, ambisi yang terlalu tinggi, jenis kelamin laki2 Umumnya akan menggunakan zat untuk menurunkan depresi dan kecemasannya serta mendapatkna
1.MODEL DIATESIS STRESS
INTEGRASI ANTARA FAKTOR BIOLOGIS, FAKTOR PSIKOSOSIAL, LINGKUNGAN, SESEORANG YANG RENTAN(DIATESIS) JIKA DIKENAI AKAN LEBIH MUDAH FAKTOR GENETIKA , 7 GEN MEMPENGARUHI, KROMOSOM 1,3,5,7,11, DAN KROMOSOM X , PENELITIAN GENETIKA INI DIHUBUNGKAN DENGAN COMT (CATECHOL-O-METHIL TRANSFERASE) DALAM ENCODING DOPAMIN SEHINGGA MEMPENGARUHI F/ DOPAMIN EMOSI TURBULENT FAMILIES, STRESSFUL LIFE EVENTS, DISKRIMINASI, KEMISKINAN DAERAH PERKOTAAN, DOWN WARD DRIFT ORANG BERGESER KE KEL SOSIAL RENDAH ATAU GAGAL KELUAR DARI KEL SOS RENDAH
2. FAKTOR NEUROBIOLOGIS ASUPAN GIZI KURANG TRAUMA PSIKOLOGIS SELAMA MASA HAMIL, ANAK, KEKERASAN PERBEDAAN STRUKTUR, FUNGSI DAERAH OTAK, PET(POSITRON EMISSION TOMOGRAPHY) DAPAT TERLIHAT KURANGNYA AKTIVITAS DI DAERAH LOBUS FRONTAL( MEMORI KERJA, PENURUNAN AKTIVITAS METABOLIK FRONTAL) KADAR PME /FOSFOMONOESTER >RENDAH KADAR PDE/FOSFODIESTER YANG >TINGGI KADAR FOSFAT INORGANIK MENURUN KONSENTRASI ATP MENINGKAT SEHINGGA TERJADILAH HIPOFUNGSI DIDAERAH KORTEKS FRONTAL DORSOLATERAL
PET, GEJALA NEGATIF= ABNORM METABOLIK > SIRKUIT FRONTAL, TEMPORAL, SEREBELAR DIBANDINGKAN GEJALA POSITIF MENURUNNYA ATENSI KARENA HIPOAKTIVITAS DI DAERAH KORTEKS SINGULAT ANTERIOR, RETARDASI MOTORIK DENGAN HIPOAKTIF DI DAERAH BASAL GANGLIA HALUSINASI TJD KARENA PERUBAHAN ALIRAN DARAH DI REGIO HIPOKAMPUS, PARA HIPOKAMPUS, AMIGDALA HALUSINASI KRONIK BERHUBUNGAN DENGAN PENINGKATAN ALIRAN DARAH DI LOBUS TEMPORAL KIRI WAHAM TERJADI PENINGKATAN ALIRAN DARAH DI LOBUS TEMPORAL MEDIAL KIRI DAN PENURUNAN DARAH DI KORTEK SINGULAT POSTERIOR DAN LOBUS TEMPORAL LATERAL KIRI GENGGUAN PENILAIAN REALITA BERHUBUNGAN DENGAN ALIRAH DARAH DI KORTEKS PREFRONTAL LATERAL KIRI, STRIATUM VENTRAL , GIRUS TEMPORALIS SUPERIOR, REGIO HIPOCAMPUS DISORGANISASI VERBAL PADA MENURUNNYA AKTIVITAS DIDAERAH KORTEKS FRONTAL INFERIOR, SINGULAT DAN TEMPORAL SUPERIOR KIRI
PENURUNAN F/KOGNITIF DIDAPATI , GANGGUAN MEMORY (SEGERA, JANGKA PENDEK/MEMORI KERJA) DAN FUNGSI EKSEKUTIF (KEMAMPUAN BERBAHASA, MEMECAHKAN MASALAH, MENGAMBIL KEPUTUSAN, ATENSI, PERENCANAAN) MRI DIDAPAT PELEBARAN DI DAERAH VENTRIKULAR III DAN LATERAL TERUTAMA BILA YANG MENONJOL ADALAH GEJALA NEGATIFNYA, INI IMPLIKASI PERUBAHAN DIDAERAH VENTRIKULAR LIMBIK STRIATA, MENGECILNYA UKURAN LOBUS FRONTAL DAN TEMPORAL, DAERAH OTAK YANG TERLIBAT ADALAH SISTEM LIMBIK, LOBUS FRONTALIS, GANGLIA BASALIS, BATANG OTAK DAN TALAMUS EEG TERLIHAT HILANGNYA GAMMA BAND MELEMAHNYA INTEGRASI ANTARA JARINGAN SARAF DI OTAK
NEUROTRAMSMITER BERHUBUNGAN DENGAN HIPOTESA DOPAMIN, SEROTONIN (5HT), GLUTAMAT DAN NMDA, GABA, NOREPINEFRIN, PEPTIDA/NEUROTENSIN. HIPOTESIS DOPAMIN (D1-D5) MENGATAKAN BAHWA RESEPTOR D2 SANGAT MEMPENGARUHI SIMPTOM POSITIF DARI SKIZOFRENIA
TEORI DOPAMIN PATHWAYS
1. MESOLIMBIK DOPAMIN PATHWAYS HIPOTESIS TERJADINYA SIMPTOM POSITIF MEMPROYEKSIKAN BADAN SEL DOPAMINERGIK KEBAGIAN VENTRAL TEGMENTUM AREA (VTA) DI BATANG OTAK KEMUDIAN KE NUKLEUS AKUMBEN DI DAERAH LIMBIK JALUR INI PENTING PADA EMOSIONAL, PRILAKU KHUSUSNYA HALUSINASI PENDENGARAN, WAHAM, GANGUAN PIKIRAN. PSIKOSTIMULAN SEPERTI AMFETAMIN, KOKAIN DAPAT MENYEBABKAN PENINGKATAN DOPAMIN, PADA JALUR INI, SHG MENYEBABKAN POSITIF SIMPTOM DAN MENIMBULKAN PSIKOSIS PARANOID JIKA PEMBERIAN ZAT INI DILAKUKAN SECARA BERULANG ANTIPSIKOTIK BEKERJA MELALUI BLOKADE RESEPTOR DOPAMIN KHUSUSNYA RESEPTOR DOPAMIN D2 SEHINGGA SIMPTOM POSITIR DAPT MENURUN ATAU MENGHILANG HIPOTESIS HIPERAKTIF MESOLIMBIK DOPAMIN PATHWAY INI MENYEBABKAN SIMPTOM POSITIF MENINGKAT, SKIZOFRENIA, PSIKOSIS YANG DISEBABKAN ZAT, MANIA, DEPRESI /DEMENSIA
HIPERAKTIF MESOLIMBIK INI PERANAN AGRESIVITAS, HOSTILITAS PENDERITA TERUTAMA BILA TERJADI PENYIMPANGAN KONTROL SEROTONERGIK DARI DOPAMIN NUKLEUS AKUMBENS ADALAH BAG SISTEM LIMBIK YANG PERANAN PADA PRILAKU SEPERTI PLEASURABLE SENSATION, POWERFUL EUPHORIA PADA INDIVIDU YANG MEMILIKI WAHAM, HALUSINASI SERTA PADA PENGGUNAAN ZAT JUGA MEMPUNYAI PERANAN PLEASURE REWARD, REINFORCING BEHAVIOR, PADA PENYALAHGUNAAN ZAT MENIMBULKAN KETERGANTUNGAN KARENA TERJADI
2.MESOKORTIKAL DOPAMIN PATHWAY
INI DIMULAI DARI DAERAH VENTRAL TEGMENTUM AREA KE DAERAH SEREBRAL KORTEKS KHUSUSNYA KORTEKS LIMBIK, PERANAN MESOKORTIKAL DOPAMIN PATHWAY ADALAM SEBAGI MEDIASI DARI SIMPTOM NEGATIF DAN KOGNITIF SKIZOFRENIA SIMPTOM NEGATIF DAN KOGNITIF DISEBABKAN TURUNNYA DOPAMIN DI JALUR MESOKORTIKAL TERUTAMA DAERAH DORSO LATERAL PREFRONTAL
DEFISIT BEHAVIORAL YANG DINYATAKAN DALAM SUATU SIMPTOM NEGATIF BERUPA PENURUNAN AKTIFITAS MOTORIK, AKTIFITAS YANG BERLEBIHAN DARI SISTEM GLUTAMAT YANG BERSIFAT EKSITOTOKSIS PADA SISTEM SARAF (BURN OUT) YANG KEMUDIAN BERLANJUT MENJADI SUATU PROSES DEGENERASI DI MESOKORTIKAL DOPAMIN PATHWAY. INI AKAN MEMPERBERAT SIMPTOM NEGATIF DAN MENINGKATKAN DEFISIT YANG TERJADI PADA SKIZOFREN MENINGKATKNA DOPAMIN MEMPERBAIKI SIMPTOM NEGATIF DAN KOGNITIF OBAT ANTIPSIKOTIK GENERASI 2, DAPAT BEKERJA SECARA SELEKTIF, MENYEBABKAN DOPAMIN DI MESOLIMBIK MENURUN SEDANGKAN DOPAMIN DI MESOKORTEK MENINGKAT
DARI SUBSTANSIA NIGRA PADA BATANG OTAK KE DAERAH BASAL GANGLIA ATAU STRIATUM BAGIAN DARI EKSTRAPIRAMIDAL BERFUNGSI PENGONTROL GERAKAN MOTORIK PENURUNAN DOPAMIN PD NIGROSTRIATAL DOPAMIN PATHWAYS DPT MENYEBABKAN GGG PERGERAKAN SEPERTI PADA PARKINSON (RIGIDITAS, AKINESIA, BRADIKINESIA (PERGERAKAN BERKURANG / MELAMBAT) DAN
3.NIGROSTRIATAL DOPAMIN PATHWAYS
PENURUNAN DOPAMIN DI DAERAH BASAL GANGLIA MENYEBABKAN AKATISIA (A TIPE OF RESTLESSNESS) DAN DISTONIA (TWISTING MOVEMENT/ PERGERAKAN KAKU) KHUSUSNYA PADA WAJAH DAN LEHER GGG PERGERAKAN JUGA DAPAT TRJDI PADA BLOKADE RESEPTOR D2 OLEH PBAT SEPERTI ANTIPSIKOTIK GENERASI 1 HIPERAKTIFITAS /PENINGKATAN DOPAMIN PD NIGROSTRIATAL MENDASARI TERJADINYA GANGGUAN PERGERAKAN HIPERKINETIK SEPERTI CHOREA, DISKIESIA DAN TICS TERJADINYA BLOKADE YANG LAMA PADA RESEPTOR D2 ->TARDIVEDISKINESIA
DIMULAI DARI HIPOTALAMUS KE HIPOFISIS ANTERIOR (ANTERIOR PITUITARY) DALAM KEADAAN NORMAL TUBEROINFUDIBULAR DIPENGARUHI OLEH INHIBISI DAN PELEPASAN PROLAKTIN PENURUNAN AKTIFITAS PROLAKTIN SETELAH MELAHIRKAN BERHUBUNGAN DENGAN PENINGKATAN PROLAKTIN PADA ASI PENINGKATAN PROKLATIN ANTARA LAIN KARENA TERJADINYA KARENA LESI ATAU PEMAKAIAN OBAT ANTIPSIKOTIK MANIFESTASI KLINIK PENINGKATAN PROLAKTIN GALAKTORE (SEKRESI ASI), AMENOREA, DISFUNGSI SEKSUAL, TERJADI SELAMA ATAY SETELAH PEMBERIAN OBAT ANTIPSIKOTIK
4.TUBEROINFUNDIBULAR DOPAMIN PATHWAYS
ADA 5 HIPOTESIS PERKEMBANGAN NEURON PADA PENDERITA SKIZOFRENIA 1. ABNORMARLITAS PERKEMBANGAN OTAK JANIN SELAMA FASE AWAL DARI SELEKSI NEURON DAN MIGRASI 2. TERJADINYA PROSES DEGENERASI ABNORMAL YANG MUNGKIN BERHUBUNGAN DENGAN GENETIK DALAM PERKEMBANGAN OTAK JANIN 3.SIMPTOM DARI INI TIDAK TERJADI SELAMA OTAK DAPAT MEMPERBAIKI SINAP2 YANG MENGALAMI GANGGUAN 4.INFEKSI VIRUS, KURANG GIZI, AUTOIMUN SELAMA MASA HAMIL MEMPENGARUHI NEURON JANIN SELAMA DALAM KANDUNGAN DAN DPT MENJADI PERANTARA TERJADINYA NEKROSIS NEURON DIKEMUDIAN HARI 5.PERUBAHAN STRUKTUR DAN ABNORMALITAS DARI NEURON YANG MASIH BERFUNGSI MENGAKIBATKAN TERJADI INERVASI DARI SINYAL DARI NEURON YANG
NEURODEGERATIF DAN NEUROTOKSISITAS
HIPOTESIS NEURODEGENERATIF PADA PS SKIZOFRENIA
PENURUNAN FUNGSU NEURONAL SECARA PROGRESIF DAN TERUS MENERUS SLM SKIZO PERJALANAN DARI FASE ASIMPTOMATIK PADA USIA BELASAN TAHUN (FASE 1), BERLANJUT PRODROMAL(ODDNESS ATAU ANEH) DAN ONSET SIMPTOM NEGATIF YANG TIDAK KHAS PADA AKHIR USIA BELASAN KE AWAL USIA 20 AN, (FASE II). FASE AKTIF DARI SKIZOFRENIA BARU MULAI DAN BERLANJUT SETELAH USIA 20AN DAN 30 AN DITANDAI DENGAN SIMPTOM POSITIF , TIDAK PERNAH KEMBALI LAGI PADA TARAF FUNGSI YANG SEMULA KEMUDIAN DIIKUTI DENGAN RELAPS AKUT DAN EKSASERBASI AKUT (FASE III), AKHIRNYA SKIZOFRENIA MENJADI STABIL SETALAH TERJADI PERBURUKAN FUNGSI NEGATIF DAN KOGNITIF, YANG MENONJOL DAN PENURUNAN DARI BASELINE FUNGTIONAL ISTILAH BURN OUT UMUMNYA TERJADI PADA USIA 40 AN ATAU LEBIH
GLUTAMAT ASAM AMINO ESENSIAL , NEUROTRANSMITER –GLUTAMATERGIK BERSIFAT EKSITASI DI SSP RESEPTOR DARI GLUTAMATERGIK –MENGATUR MIGRASI DARI NEURON, PERTUMBUHAN NEURIT, SINAPTOGENESIS, APOPTOSIS NEURODEGERATIF PD SKIZOFR DI MEDIASI MELALUI AKSI DARI NEUROTRANSMITER GLUTAMAT YANG BERLEBIHAN DAN DIKETAHUI TERNYATA BERSIFAT EKSITOSIS SHG MENIMBULKAN KEMATIAN INTRASELULER NEURON NEUROTRANSMITER GLUTAMAT TERDAPAT DIDAERAH SEREBELUM, HIPOKAMPUS,
GLUTAMAT DISINTESIS DARIGLUKOSA DAN GLUTAMIN DIDAERAH TERMINAL PRESINAP DAN DISIMPAN DALAM VESIKAL SINAP, KEMUDIAN GLUTAMAT AKAN DILEPASKAN DARI VESIKEL KE CELAH SINAP, NEUROTRANSMITER INI AKAN BEKERJA PADA RESEPTOR DAN AKTIVITASNYA DIBATASI OLEH MEKANISME REUPTAKE GLUTAMIN MERUPAKAN PREKURSOR YANG PENTING DARI GLUTAMAT, NIKOTIN AKAN MENSTIMULASI PELEPASAN GLUTAMAT KE CELAH SINAP JADI HIPOTESIS EKSITOTOKSIS PADA SKIZOFREN KAREAN DEGENERASI NEURON DISEBABKAN EXCESSIVE EKSITATORY NEUROTRANSMITTER GLUTAMATE SHG MENIMBULKAN SUATU APNORMAL RESIPROCAL GLUTAMATERGIZ CORTOCO THALAMIC CIRCUIT
RESEPTOR GLUTAMAT ADA 5
1. NMDA (N-METHYL-D-ASPARTANTE) 2. AMPA (ALPHA AMINO 3 HYDROXY 5 METHYL 4 ISOXAZOLE PROPIONIC ACID 3. KAINATE 4.L-AP4 (L-2-AMINO-4-PHOSPHONOBUTYRATE) 5. ACPD (TRANS-1-AMINOCYCLOPENTANE-1,3 DICARBOXYLIC ACID) RESEPTOR NMDA,AMPA, KAINATE BERHUBUNGAN DENGAN ION CHANEL, RESEPTOR INI DISEBUT RESEPTOR IANOTTROPIK KARENA MEMPUNYAI KANAL SPECIFIK UNTUK KATION (NA,K,CA) SHG TJD AKTIVASI CEPAT DAN DALAM WAKTU CEPAT RESEPTOR METABOTROPIK ADALAH RESEPTOR YANG BERFUNGSI MENGAKTIFKAN SECOND MESSENGER SPT CYCLIC ADENOSINE MONOPHOSPHATE (CMAP) TETAPO DALAM HAL INI BUTUH WAKTU LAMA
EKSITOSIS MEMEDIASI TERJADINYA GANGGUAN NEUROLOGIK DAN GANGGUAN PSIKIATRI MLL NEUROGENESIS, MEKANISME EKSITOSIS MENYEBABKAN PATOLOGI DI DAERAH SINAP GLUTAMAT JUGA PERANAN PATOFIFIOLOGI SKIZOFRENIA TERUTAMA SIMPTOM POSITIF DAN NEGATIF OBAT ANTIPSIKOTIK MEMPNGARUHI NEUROTRANSMITER GLUTAMAT DENGAN MENINGKATKAN PELEPASANNYA, INTERAKSI DENGAN RESEPTOR GLUTAMAT ATAU DENGAN MEMPENGARUHI DENSITAS MAUPUN KOMPOSISI SUB UNIT DARI RESEPTOR GLUTAMAT NEUROGENETIK PADA SKIZOFREN DPT KARENA: ANOKSIA JANIN, TOKSIN SELAMA HAMIL, KURANG GIZI SLM HAMIL, INFEKSI JANIN, DESTRUKSI PROGRAM GENETIK
DIAGNOSIS SKIZOFRENIA MENURUT DSM IV-TR
A.TERDAPAT 2 ATAU LEBIH GEJALA DIBAWAH INI SELAMA 1 BULAN ATAU KURANG DARI SEBULAN JIKA PENGOBATAN BERHASIL 1. WAHAM. 2. HALUSINASI. 3. BICARA DISORGANISASI. 4. PERILAKU DISORGANISASI/KATATONIK YANG JELAS. 5. SIMPTOM NEGATIF (AFEK DATAR, ALOGIA, AVOLITION
NOTE = DAPAT HANYA 1 GEJL BILA DIJUMPAI WAHAM
DISFUNGSI SOSIAL /PEKERJAAN C. DURASI GANGGUAN TERUS MENERUS SELAMA 6 BULAN D.DISINGKIRKAN GANGGUAN SKIZOAFEKTIF DAN GANGGUAN MOOD E. DISINGKIRKAN GANGGUAN PENGGUNAAN ZAT ATAU KONDISI MEDIS UMUM F.JIKA TERDAPAT GANGGUAN PERKEMBANGAN PERVASIF, DIAGNOSIS TAMBAHAN SKIZOFRENIA DIBUAT BILA WAHAM DAN HALUSINASI MENONJOL
1.TIPE KATATONIK TERDAPAT 2/> GEJALA BERIKUT INI 1. IMMOBILITAS MOTORIK BERUPA KATALEPSI, WAXY FLEKSIBILITAS/STUPOR 2. AKTIVITAS MOTORIK YANG BERLEBIHAN, TETAPI TIDAK MEMILIKI TUJUAN DAN TIDAK DIPENGARUHI OLEH STIMULI EKSTERNAL 3. NEGATIVISME YANG EKSTRIM, MUTISME 4. GERAKAN VOLUNTER YANG ANEH, DITUNJUKAN OLEH POSTURING, GERAKAN STEREOTIPIK, MANERISME, ATAU GRIMACING (SERINGAI) YANG MENONJOL
SUBTIPE SKIZOFRENIA DSM IV TR
2. TYPE DISORGANISASI (HEBEFRENIK) SEMUA KRITERIA DIBAWAH INI TERPENUHI A. MENONJOLNYA DISORGANISASI BICARA DAN PERILAKU, AFEK DATAR/AFEK TIDAK SESUAI B. KRITERIA SKIZOFRE KATATONIK TDK TERPENUHI 3. TYPE PARANOID SEMUA KRITERIA INI TERPENUHI YAITU: G. PREOKUPASI DGN WAHAM/HALUSINASI DENGAR YANG MENONJOL H. KRITERIA SKIZOFRENIA TIPE DIORGANISASI TIDAK TERPENUHI 4. TYPE TIDAK TERGOLONGKAN (UNDIFERENTIATED TYPE) TIDAK MEMENUHI KRITERIA UNTUK TIPE PARANOID, DISORGANISASI /KATATONIK
TYPE RESIDUAL A. TIDAK TERDAPAT WAHAM, HALUSINASI, DISORGANISASI BICARA, PERILAKU KATATONIK/DISORGANISASI PERILAKU YG MENONJOL B. TERDAPAT TERUS MENERUS GANGGUAN SPT DITUNJUKNA OLEH ADANYA GEJALA NEGATIF/ 2 /LEBIH GEJALA DARI KRITERIA A MENURUT DSM IV TR DARI SKIZOFRENIA DALAM BENTUK LEBIH RINGAN *KEYAKINANA YANG ANEH, PENGALAMAN PERSEPSI
6. SKIZOFRENIA SIMPLEKS (GANGGUAN DETERIORATIF SEDERHANA) KRITERI DIAGNOSTIK DSM IV TR A.PERKEMBANGAN YANG BERSIFAT PROGRESIF DAN SUDAH BERLANGSUNG MINIMAL 1 TAHUN, DAPAT BERUPA: 1. PENURUNAN YG NYATA DALAM F/ PEKERJAAN/AKADEMIK 2. PENAMPAKAN DAN PENDALAMAN SECARA BERTAHAP DARI SIMPTOM NEGATIF 3. RAPPORT INTERPERSONAL YANG BURUK, ISOLASI SOSIAL ATAU PENARIKAN
KRITERIA MENURUT PPDGJ III YANG AMAT JELAS APABILA ADA 1/ > GEJALA
BIASANYA 2/> GEJALA KURANG JELAS/KURANG TAJAM) DARI GEJALA DIBAWAH INI A. THOUGHT ECHO, THOUGHT INSERTION/ WITHDRAWAL/ THOUGHT BROADCASTING B. DELUSION OF CONTROL, DELUSION OF INFLUENCE/ DELUSION OF PASSIVITY C. HALUSINASI SUARA BERUPA KOMENTAR TERUS MENERUS/MENDISKUSIKAN TENTANG PS
MINIMAL TERDAPAT 2 GEJALA DARI GEJALA2 DIBAWAH INI APABILA SEMUA GEJALA DIATAS TIDAK DITEMUKAN E. HALUSINASI YANG MENETAP F. ARUS PIKIRAN YANG TERPUTUS ATAU MENGALAMI SISIPAN SEHINGGA INKOHEREN/ PEMBICARAANNYA TIDAK RELEVAN G. PERILAKU KATATONIK H. GEJALA NEGATIF GEJALA A,B,C,D,E,F,G,H KHAS DAN BERLANGSUNG 1 BULAN/> KRITERUA INI TIDAK DAPAT DIGUNAKAN BILA PENDERITA MASIH FASE PRODROMAL
SKIZOFRENIA TDK DAPAT DITEGAKKAN BILA TERDAPAT: GEJALA DEPRESIF/MANIK SCR LUAS, PENYAKIT OTAK NYATA/EPILEPSI (LAIN) INTOKSIKASI, WITHDRAWAL ZAT 5. APABILA GEJALA SKIZOFRENIA DAN GEJ AFEKTIF BERKEMBANG BERSAMA-SAMA SECARA SEIMBANG DAN SAMA BANYAK MAKA GANGUAN TERSEBUT DIKENAL GANGGUAN SKIZOAFEKTIF
TYPE SKIZOFRENIA MENURUT PPDGJ III 1. TYPE PARANOID (F20.0) A. MERUPAKAN TYPE YANG PALING SERING DITEMUKAN B. GAMBARAN KLINIS DIDOMINASI OLEH WAHAM YANG BERSIFAT STABIL, BIASANYA DISERTAI OLEH HALUSINASI DAN GANGGUAN PERSEPSI C. KRITERIA DIAGNOSTIK - HALUSINASI/WAHAM HARUS MENONJOL - GANGGUAN AFEKTIF, DORONGAN KEHENDAK DAN PEMBICARAAN SERTA GEJALA KATATONIK YANG TIDAK NYATA
- HALUSINASI PENDENGARAN DPT BERUPA ANCAMAN, PERINTAH KPD PASIEN ATAU HALUSINASI TANPA BENTUK VERBAL SEPERTI BUNYI PLUIT, BERDENGUNG, TAWA. HALUSINASI PENCIUMAN ATAU PENGECAPAN RASA/BERSIFAT SEXUAL - WAHAM YANG BERUPA DIKENDALIKAN, DIPENGARUHI, PASSIVITY / KEJAR. PALING KHAS WAHAM KEJAR
TIPE HEBEFRENIK (F20-1) - MENEGAKKAN DIAGNOSIS SKIZOFRENIA TIPE HEBEFRENIK INI PERLU DILAKUKAN OBSERVASI SELAMA 2-3 BULAN UNTUK MELIHAT APAAH GEJALA TERSEBUT BERTAHAN ATAU TIDAK - TERDAPAT GANGGUAN AFEKTIF, DORONGAN KEHENDAK DAN GANGGUAN PROSES PIKIR YANG MENONJOL CIRI KHAS TYPE INI ADALAH ADANYA PERILAKU TANPA TUJUAN DAN TANPA
TIPE KATATONIK (F20.2) 1. SKIZOFRENIA TIPE INI JARANG DITEMUKAN 2. KRITERIA DIAGNOSTIK - TERPENUHI KRITERIA SKIZOFRENIA - TERDAPAT 1/ > GEJALA2 SPT: STUPOR/MUTISME, KEGELISAHAN, POSTURING, NEGATIVISME, RIGIDITAS, WAXY FLEXIBILITAS / COMMAND OUTOMATISME 3. APABILA PASIEN TIDAK KOMUNIKATIF DAN TERDAPAT MANIFESTASI PERILAKU KATATONIK MAKA UNTUK SEMENTARA PENEGAKAN DIAGNOSIS HARUS DITUNDA SAMPAI ADA BUKTI
KRITERIA SKIZOFRENIA TERPENUHI TAPI TIDAK MEMENUHI TYPE YANG LAIN 5. TYPE RESIDUAL TYPE INI MERUPAKAN STADIUM KRONIS KRITERIA DIAGNOSTIK - GEJALA NEGATIF MENONJOL - ADA RIWAYAT SATU EPISODE PSIKOTIK YANG JELAS DIMASA LALU YANG MEMENUHI KRITERIA SKIZOFREN - PALING SEDIKIT MELAMPAUI KURUN WAKTU 1 TAHUNM INTENSITAS DAN FREKUENSI GEJALA YANG NYATA SANGAT BERKURANG DAN TELAH MENIMBULKAN SINDROM NEGATIF - TIDAK TERDAPAT DIMENSIA, PENYAKIT OTAK ORGANIK, ATAU DEPRESI KRONIS
4. TIPE TAK TERINCI (UNDIFFERENTIATED) F20.3
TIPE SIMPLEKS (F20.6) A. SIMPTOM NEGATIF BERSIFAT BERLAHAN2 TAPI PROGRESIF B. TDK TERDAPAT WAHAM DAN HALUSINASI C. KURANG NYATA GEJALA PSIKOTIK JUKA DIBANDINGKAN DENGAN SKIZOFRENIA TIPE LAIN D.SIMPTOM NEGATIF TIMBUL TANPA DIDAHULUI OLEH GEJALA2 PSIKOTIK YANG NYATA
TIPE DEPRESI PASCE SKIZOFRENIA (F.20.4) A. SKIZOFRENIA SUDAH BERLANGSUNG 1 TAHUN B. GEJALA SKIZOFRENIA MASIH TETAP ADA C. TERDAPAT GEJALA2 DEPRESIF YANG MENONJOL DAN MENGGANGGU, MEMENUHI EPISODE DEPRESIF DAN BERLANGSUNG MIN 2 MINGGU
POLA PERJALANAN SKIZOFRENIA MENURUT PPDGJ III DENGAN KODE 5 KARAKTER F20.X. 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
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
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 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 – – – – – – Other disorders of perception Sudden delusional ideas Perplexity Depressive and euphoric mood changes Feelings of emotional impoverishment â€œâ€¦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 A type of schizophrenia in which the following criteria are met: Absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior. There is continuing evidence of the disturbance, as indicated by the presence of negative symptoms or two or more symptoms listed in Criterion A for schizophrenia, present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).
The following case illustrates ideas of reference and paranoid delusions. A married man, age 38, with a history of dependable, conscientious work as a bookkeeper, became sleepless, anxious, and unable to concentrate. He developed the belief that his vision was failing because of poisons secretly placed in his food by former neighbors. He found a misprint in a newspaper that he felt was placed there by the editor to shame him publicly. Admitted to the psychiatric service of a general hospital, he said that cars passing up and down the street contained agents who were spying on him. He believed that the electric light bulbs in his room were emanating a purifying radiation to counteract syphilitic germs, which he was supposedly breathing into the atmosphere, although a physical examination was negative for syphilis.
Disorganized Type The disorganized (formerly called hebephrenic) type of schizophrenia is characterized by a marked regression to primitive, disinhibited, and unorganized behavior and by the absence of symptoms that meet the criteria for the catatonic type. The onset of this subtype is generally early, occurring before age 25. Disorganized patients are usually active but in an aimless, nonconstructive manner. Their thought disorder is pronounced, and their contact with reality is poor. Their personal appearance is disheveled, and their social behavior and their emotional responses are inappropriate. They often burst into laughter without any apparent reason. Incongruous grinning and grimacing are common in these patients, whose behavior is best described as silly or fatuous.
Patient AB, a 32-year-old woman, began to lose weight and became careless about her work, which deteriorated in quality and quantity. She believed that other women at her place of employment were circulating slanderous stories concerning her and complained that a young man employed in the same plant had put his arm around her and insulted her. Her family demanded that the charge be investigated, which showed not only that the charge was without foundation but also that the man in question had not spoken to her for months. One day she returned home from work, and as she entered the house, she laughed loudly, watched her sister-in-law suspiciously, refused to answer questions, and at the sight of her brother began to cry. She refused to go to the bathroom, saying that a man was looking in the windows at her. She ate no food, and the next day declared that her sisters were bad women, that everyone was talking about her, and that someone had been having sexual relations with her, and although she could not see
The patient was admitted to a public psychiatric hospital. As she entered the admitting office, she laughed loudly and repeatedly screamed in a loud tone, She cannot stay here; she's got to go home She grimaced and performed various stereotyped movements of her hands. When seen on the ward an hour later, she paid no attention to questions, although she talked to herself in a childish tone. She moved about constantly, walked on her toes in a dancing manner, pointed aimlessly about, and put out her tongue and sucked her lips in the manner of an infant. At times she moaned and cried like a child but shed no tears. As the months passed, she remained silly, childish, preoccupied, inaccessible, grimacing, gesturing, pointing at objects in a stereotyped way, and usually chattering to herself in a peculiar high-pitched voice, with little of what she said being understood. Her condition continued to deteriorate, she remained unkempt, and she presented a picture of extreme introversion and regression, with no interest either in the activities of the institution or in her relatives who visited her. (Adapted from case of Arthur P. Noyes, M.D., and Lawrence C. Kolb, M.D.)
AC, age 32, was admitted to the hospital. On arrival, he was noted to be an asthenic, poorly nourished man with dilated pupils, hyperactive tendon reflexes, and a pulse rate of 120. He showed many mannerisms, laid down on the floor, pulled at his foot, made undirected violent striking movements, struck attendants, grimaced, assumed rigid and strange postures, refused to speak, and appeared to be having auditory hallucinations. When seen later in the day, he was found to be in a stuporous state. His face was without expression, he was mute and rigid, and he paid no attention to those about him or to their questions. His eyes were closed, and
He gradually became accessible, and when asked concerning himself, he referred to his stuporous period as sleep and maintained that he had no recollection of any events occurring during it. He said, didn't know anything. Everything seemed to be dark as far as my mind is concerned. Then I began to see a little light, like the shape of a star. Then my head got through the star gradually. I saw more and more light until I saw everything in a perfect form a few days ago. He explained his mutism by saying that he had been afraid he would say the wrong thing and also that he didn't know exactly what to talk about. From his obviously inadequate emotional response and his statement that he was a scientist and an inventor of the most extraordinary genius of the twentieth century, it was plain that he was still far
Frequently, patients who are clearly schizophrenic cannot be easily fit into one type or another. DSM-IV-TR classifies these patients as having schizophrenia of the undifferentiated type. A 15-year-old girl attended a summer camp, where she had difficulties getting along with the other children and developed animosity toward one of the counselors. On her return home, she refused to listen to her parents and said she heard the voice of a man talking to her, although she could not see him. She rapidly began to show bizarre behavior, characterized by grimacing, violent outbursts, and inability to take care of herself. Her school record has always been good, and she was fluent in three languages. Her parents described her as having been a quiet, rather shut-in child with no abnormal traits in childhood. Family relations were reported as having been satisfactory. On admission to a psychiatric hospital, the patient's speech was incoherent. She showed marked disturbances of formal thinking and blocking of thoughts. She was impulsive and appeared to be hallucinating. She stated that she heard voices in her right ear that a popular singer was running after her with a knife. She also thought that her father was intent on killing her. She thought that
She was often incontinent, and most of the time neglected her physical appearance. But occasionally she spent hours dressing herself, looking in the mirror, and putting on excessive makeup. At times, she was eating her feces. Occasionally, she adopted the roles of a singer or dancer. She made incoherent statements like: Will I live forever? Nurse, I don't throw may love away. It is my stomach and it hurts. In the dining room, she attempted to grasp the genitals of male patients. Two months of neuroleptic treatment brought no apparent improvement. She was given a course of electroconvulsive therapy (ECT). She remained in the hospital, where her behavior continued to be very distrubed.
Residual Type According to DSM-IV-TR, the residual type of schizophrenia is characterized by continuing evidence of the schizophrenic disturbance in the absence of a complete set of active symptoms or of sufficient symptoms to meet the diagnosis of another type of schizophrenia. Emotional blunting, social withdrawal, eccentric behavior, illogical thinking, and mild loosening of associations commonly appear in the residual type. When delusions or hallucinations occur, they are neither prominent nor accompanied by strong affect (Fig. 13-7). Other Subtypes The subtyping of schizophrenia has had a long history; other subtyping schemes appear in the literature, especially literature from countries other than the United States.
term paraphrenia is sometimes used as a synonym for paranoid schizophrenia, or for either a progressively deteriorating course of illness or the presence of a wellsystemized delusional system. The multiple meanings of the term render it ineffectual in communicating information.
Pseudoneurotic Schizophrenia Occasionally, patients who initially have such symptoms as anxiety, phobias, obsessions, and compulsions later reveal symptoms of thought disorder and psychosis. These patients are characterized by symptoms of pananxiety, panphobia, panambivalence, and sometimes chaotic sexuality. Unlike persons with anxiety disorders, pseudoneurotic patients have free-floating anxiety that rarely subsides. In clinical descriptions, the patients seldom become overtly and severely psychotic. This condition is currently diagnosed in DSM-IVTR as borderline personality disorder.
Simple Deteriorative Disorder
Simple Deteriorative Disorder (Simple Schizophrenia) Simple deteriorative disorder is characterized by a gradual, insidious loss of drive and ambition. Patients with the disorder are usually not overtly psychotic and do not experience persistent hallucinations or delusions. Their primary symptom is withdrawal from social and workrelated situations. The syndrome must be differentiated from depression, a phobia, a dementia, or an exacerbation of personality traits. Clinicians should be sure that patients truly meet the diagnostic criteria for schizophrenia before making the diagnosis. Simple deteriorative disorder appears as a diagnostic category in an
Simple Deteriorative Disorder (Simple
An unmarried man, 27 years old, was brought to the mental hospital because he had on several occasions become violent toward his father. For a few weeks, he had hallucinations and heard voices. The voices eventually ceased, but he then adopted a strange way of life. He would sit up all night, sleep all day, and become very angry when his father tried to get him out of bed. He did not shave or wash for weeks, smoked continuously, ate very irregularly, and drank enormous quantities of tea. In the hospital, he adjusted rapidly to the new environment and was found to be generally cooperative. He showed no marked abnormalities of mental state or behavior, except for his lack of concern for just about anything. He kept to himself as much as possible and conversed little with patients or staff. His personal hygiene had to be supervised by the nursing staff; otherwise, he would quickly become dirty and untidy. Six years after his admission to the hospital, he is described as shiftless and careless, sullen and unreasonable. He lies on a couch all day long. Although many efforts have been made to get the patient to accept therapeutic work assignments, he refuses to consider any kind of regular occupation. In the summer, he wanders about the hospital grounds or lies under a tree. In the winter, he wanders
DSM-IV-TR Research Criteria for Simple Deteriorative Disorder (Simple Schizophrenia) Progressive development over a period of at least a year of all of the following:
– marked decline in occupational or academic functioning – gradual appearance and deepening of negative symptoms such as affective flattening, alogia, and avolition – poor interpersonal rapport, social isolation, or social withdrawal
Criterion A for schizophrenia has never been met. The symptoms are not better accounted for by schizotypal or schizoid personality disorder, a
Suicide is the single leading cause of premature death among people with schizophrenia. Suicide attempts are made by 20 to 50 percent of the patients, with longterm rates of suicide estimated to be 10 to 13 percent. These numbers reflect an approximately 20-fold increase over the suicide rate in the general population. Often, suicide in schizophrenia seems to occur â€œout of the blue, without prior warnings or expressions of verbal intent. The most important factor is the presence of a major depressive episode. Epidemiological studies indicate that up to 80 percent of schizophrenia patients may have a major depressive episode at some time in their lives. Some data suggest that those patients with the best prognosis (few negative symptoms, preservation of capacity to experience affects, better abstract thinking) can paradoxically also be at highest risk for suicide. The profile of the patient at greatest risk is a young man
who once had high expectations, declined from a higher level of functioning, realizes that his dreams are not likely to come true, and has lost faith in the effectiveness of treatment. Other possible contributors to the high rate of suicide include command hallucinations and drug abuse. Two-thirds or more of schizophrenic patients who commit suicide have seen an apparently unsuspecting clinician within 72 hours of death. A large pharmacological study suggests that clozapine (Clozaril) may have particular efficacy in reducing suicidal ideation in schizophrenia patients with prior hospitalizations for suicidality. Adjunctive antidepressant medications have been shown to be effective in alleviating cooccurring major depression in schizophrenia.
The following is an example of an unpredictable suicide in a schizophrenic who had been responding to psychiatric treatment: The patient had been an autistic child and did not speak until he was 7 years old. He had responded well to psychiatric treatment, and at age 13 his IQ was reported as 122. At age 17 he became violent toward his parents, shaved all his hair off, and made such statements as, I like bank robbers knocking people unconsciousand I think tough gangs are funny because they beat down people. While saying this, he laughed loudly. He was admitted to a mental hospital, where he responded with definite improvement to pharmacotherapy and psychotherapy, and he went home regularly for weekends.
He left various notes on his desk before committing suicide. Among these notes was an eight-page list giving 211 excusable mistakes throughout my life. Each one was dated, for example, 1952, 2nd of November: throwing up in my friend's house on a shoe-box. 1953, 17th August: accidentally wearing a watch that wasn't water-proof in the bath-tub. 1956, 23rd of September: slamming back-door of Meteor after getting in. He then proceeded in his notes to give the causes of the mistakes:Montreal having a mountain; I have a receding hair-line; my height since I was nine years old; Canada having two languages He also wrote: My feelings of tension since 1962 is getting worse most of the time. I planned the date of my death without the slightest trace of emotion The boy hanged himself at age 18 in the family garage. An experienced psychiatrist who had repeatedly interviewed him noted no signs of
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
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
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 â€œprovisional.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
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.
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
An uninterrupted period of illness during which, at some time, there is either a major depressive episode, a manic episode, or a mixed episode concurrent with symptoms that meet Criterion A for schizophrenia. Note: The major depressive episode must include Criterion A1: depressed mood. During the same period of illness, there have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms. Symptoms that meet criteria for a mood episode are present for a substantial portion of the total duration of the active and residual periods of the illness. 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. Specify type: Bipolar type: if the disturbance includes a manic or a mixed episode (or a manic or a mixed episode and major depressive episodes) Depressive type: if the disturbance only includes major depressive episodes
Mrs. P was a 47-year-old, divorced, unemployed woman who lived alone and was chronically psychotic despite treatment with olanzapine, 20 mg per day, and citalopram (Celexa), 20 mg per day. She believed that she was getting messages from God and the police department to go on a mission to fight drug dealers. She also believed that the Mafia was trying to stop her in this pursuit. The onset of her illness began at 20 years of age, when she experienced the first of several depressive episodes. She also described periods when she felt more energetic, talkative, had decreased need for sleep, and was more active, sometimes cleaning her house the whole night. Approximately 4 years after the onset of her symptoms, she began to hear voices that became stronger when she got depressed, but were still present and continued to disturb her even when her mood was euthymic. Approximately 10 years after her illness began, she developed the belief that policemen were everywhere and that the neighbors were spying on her. She was hospitalized voluntarily. Two years later, she had another depressive episode, and the voices told her she could not live in her apartment. She was tried on lithium, antidepressants, and antipsychotic medications but continued to be chronically symptomatic with mood symptoms as well as psychosis. (Courtesy of Shmuel Fennig, M.D., Laura J. Fochtmann, M.D., and Gabrielle A. Carlson, M.D.)
Differential Diagnosis The psychiatric differential diagnosis includes all the possibilities usually considered for mood disorders and for schizophrenia. In any differential diagnosis of psychotic disorders, a complete medical workup should be performed to rule out organic causes for the symptoms. A history of substance use (with or without positive results on a toxicology screening test) may indicate a substance-induced disorder. Preexisting medical conditions, their treatment, or both can cause psychotic and mood disorders. Any suspicion of a neurological abnormality warrants consideration of a brain scan to rule out anatomical pathology and an electroencephalogram (EEG) to determine any possible seizure disorders (e.g., temporal lobe epilepsy). Psychotic disorder caused by seizure disorder is more common than that seen in the general population. It tends to be characterized by paranoia, hallucinations, and ideas of reference. Patients with epilepsy with psychosis are believed to have a better level of function than patients with schizophrenic spectrum disorders.
ICD-10 Diagnostic Criteria for Schizoaffective Disorders Note: This diagnosis depends upon an approximate balance between the number, severity, and duration of the schizophrenic and affective symptoms. G1. The disorder meets the criteria for one of the affective disorders of moderate or severe degree, as specified for each category. G2. Symptoms from at least one of the groups listed below must be clearly present for most of the time during a period of at least 2 weeks (these groups are almost the same as for schizophrenia): Thought echo, thought insertion or withdrawal, thought broadcasting (Criterion G1a for paranoid, hebephrenic, or catatonic schizophrenia); Delusions of control, influence, or passivity,
Hallucinatory voices giving a running commentary on the patient's behavior or discussing the patient among themselves, or other types of hallucinatory voices coming from some part of the body (Criterion G1c for paranoid, hebephrenic, or catatonic schizophrenia); Persistent delusions of other kinds that are culturally inappropriate and completely impossible, but not merely grandiose or persecutory (Criterion G1d for paranoid, hebephrenic, or catatonic schizophrenia), e.g., has visited other worlds; can control the clouds by breathing in and out; can communicate with plants or animals without speaking; Grossly irrelevant or incoherent speech, or frequent use of neologisms (a marked form of Criterion G1b for paranoid, hebephrenic, or
Intermittent but frequent appearance of some forms of catatonic behavior, such as posturing, waxy flexibility, and negativism (Criterion G1c for paranoid, hebephrenic, or catatonic schizophrenia). G3. Criteria G1 and G2 above must be met within the same episode of the disorder, and concurrently for at least part of the episode. Symptoms from both G1 and G2 must be prominent in the clinical picture. G4. Most commonly used exclusion clause. The disorder is not attributable to organic mental disorder, or to psychoactive substance-related intoxication, dependence, or withdrawal.Schizoaffective disorder, manic type The general criteria for schizoaffective disorder must be met. Criteria for a manic disorder must be met. Other schizoaffective disorders Schizoaffective disorder, unspecifiedComments If desired, further subtypes of schizoaffective disorder may be specified, according to the longitudinal development of the disorder, as follows: Concurrent affective and schizophrenic symptoms only Symptoms as defined in Criterion G2 for schizoaffective disorders Concurrent affective and schizophrenic symptoms beyond the duration of affective symptoms(Reprinted with permission from World Health Organization. The ICD-10 Classification of Mental
Treatment Mood stabilizers are a mainstay of treatment for bipolar disorders and would be expected to be important in the treatment of patients with schizoaffective disorder. One study that compared lithium with carbamazepine (Tegretol) found that carbamazepine was superior for schizoaffective disorder, depressive type, but found no difference in the two agents for the bipolar type. In practice, however, these medications are used extensively alone, in combination with each other, or with an antipsychotic agent. In manic episodes, patients who are schizoaffective should be treated aggressively with dosages of a mood stabilizer in the middle to high therapeutic blood concentration range. As the patient enters maintenance phase, the dosage can be reduced to low to middle range to avoid adverse effects and potential effects on organ systems (e.g., thyroid and kidney) and to improve ease of use and compliance. Laboratory monitoring of plasma drug concentrations and periodic screening of thyroid, kidney, and hematological functioning should be
By definition many patients who are schizoaffective have major depressive episodes. Treatment with antidepressants mirrors treatment of bipolar depression. Care should be taken not to precipitate a cycle of rapid switches from depression to mania with the antidepressant. The choice of antidepressant should take into account previous antidepressant successes or failures. Selective serotonin reuptake inhibitors (e.g., fluoxetine [Prozac] and sertraline [Zoloft]) are often used as first-line agents because they have less effect on cardiac status and have a favorable overdose profile. Agitated or insomniac patients, however, may benefit from a tricyclic drug. As in all cases of intractable mania, the use of electroconvulsive therapy (ECT) should be considered. As mentioned, antipsychotic agents are important in the treatment of the psychotic symptoms of
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