RM

1. Sakit kepala kadang

dirasa seperti mencengkeram, kadang disertai rasa bergoyang-goyang dan jalan
sempoyongan, dan kadang terasa berdenyut.
2. lebih mudah lelah,
tidak nafsu makan hingga berat badannya berkurang, tidur tidak enak karena sering
mimpi buruk, dan beberapa kali merasa sesak serta gemetar saat sakit kepalanya
muncul.
3. sudah minum obat dari beberapa dokter umum namun belum
memberikan hasil yang memuaskan
4. menjadi lebih sering sakit setahun
terakhir ini setelah ia pindah divisi di kantornya. Meski lingkungan kerja sebenarnya
kondusif, tanpa alasan yang jelas pasien semakin lama semakin mudah kepikiran
berbagai hal-hal remeh dan mudah terkejut.
5. tak lagi berminat melakukan
hubungan suami-isteri
6. sebulan terakhir pasien jadi aneh karena tibatiba menjadi takut pada laba-laba yang
sebelumnya tidak ia takuti dan sering “nge-blank”
atau tampak seperti mengantuk saat diajak bicara
7. sudah lama punya keluhan sakit lambung kambuhan, dan keluhan ini akhir-akhir ini
semakin sering muncul, bahkan disertai muntah yang menyembur dalam dua hari
terakhir

jawaban

1. VESTIBULOCOCHLEAR NERVE
(EIGHTH, VIII)
The vestibulocochlear (eighth) nerve has two components, the vestibular and cochlear
components, which
are responsible for hearing and balance, respectively.
Lesions cause deafness, tinnitus, loss of balance, vertigo
with or without vomiting, and the clinical sign of horizontal gaze-evoked jerky or rotary
nystagmus.
Causes of deafness and vertigo are listed in.

Headaches can be classified as either primary or secondary in nature. The most

common primary headache syndrome is migraine. True tension headache and cluster
headaches are uncommon. The diagnosis in these cases
is made entirely from the history because there are no
physical signs. Headache can also be secondary to other
disorders affecting the head and neck, and it is sometimes the predominant symptom of
serious intracranial
disease such as a brain tumour, infections of the brain
parenchyma or meninges or a subarachnoid haemorrhage. The most common cause of
secondary headache
is systemic infection.
Pain in the head and neck may be referred from the
ears, eyes, nasal passages, teeth, sinuses, facial bones
and cervical spine (Fig. 6.1). It is conveyed predominantly by the trigeminal nerve (fifth
cranial nerve),
and also by the seventh, ninth and tenth cranial nerves,
and the upper three cervical roots. Structures of the
anterior and middle cranial fossa generally refer pain
to the anterior two-thirds of the head through the
branches of the trigeminal nerve and structures of
the posterior fossa refer pain to the back of the head
and neck via the upper cervical roots. The brain parenchyma itself does not evoke pain,
but pain arises from
structures encasing it such as the meninges, and the
blood vessels within the brain.
Vertigo mengacu pada adanya sensasi gerakan atau perasaan seseorang
bahwa tubuhnya bergerak terhadap lingkungannya, atau lingkungan bergerak
terhadap dirinya. Rasa itu bisa dalam bentuk berputar, bergoyang atau
melayang, dapat pula disertai rasa mual sampai muntah. Gejala vertigo
memang mirip dengan migrain, akan tetapi migrain dan vertigo merupakan
penyakit yang berbeda.

Migrain adalah nyeri kepala berdenyut yang kerap kali disertai mual bahkan
muntah. Penderita biasanya sensitif terhadap cahaya, suara, bahkan bau-
bauan. Sakit kepala ini paling sering hanya mengenai satu sisi kepala saja,
kadang-kadang berpindah ke sisi sebelahnya. Tetapi, dapat mengenai kedua
sisi kepala sekaligus.

Penyebab migrain masih belum begitu jelas. Diperkirakan, adanya

hiperaktivitas impuls listrik otak meningkatkan aliran darah di otak. Akibatnya,
terjadi pelebaran pembuluh darah otak serta proses peradangan yang
menyebabkan timbulnya nyeri dan gejala yang lain, misalnya mual. Semakin
berat peradangan yang terjadi, semakin berat pula migrain yang diderita.
Telah diketahui bahwa faktor genetik berperan terhadap timbulnya migrain.

Sedangkan vertigo, biasanya tidak disertai dengan rasa sakit kecuali jenis
vertigo Vestibular. Karena penyebab vertigo adalah kita kehilangan faktor
keseimbangan tubuh yang terdiri dari tiga sistem, yaitu:

1. Sistem vestibular (sistem keseimbangan di telinga dalam). Gangguannya

disertai sakit kepala dan dibedakan menjadi dua tipe.

- Tipe sentral, gangguan terjadi pada batang otak sampai otak besar;

- Tipe perifer, gangguan terletak pada batang otak sampai labirin di telinga
bagian dalam.

2. Sistem visual (penglihatan).

3. Sistem somatosensorik atau proprioseptik (sistem saraf sumsum tulang

belakang). Gangguannya tidak disertai sakit kepala.

Vertigo muncul jika ada gangguan pada salah satu, atau lebih dari ketiga
sistem keseimbangan itu. Sehingga, dunia ini serasa berputar atau
bergoyang. Ini biasanya diakibatkan, oleh tertekannya unsur penyeimbang
tubuh yang terletak di saraf belakang telinga atau adanya infeksi sistem
vestibular perifer (gangguan pada telinga bagian dalam). Pusing juga bisa
muncul sebagai akibat dari gangguan sistem vestibular sentral (misalnya
saraf vestibular, batang otak, dan otal kecil).

Gangguan keseimbangan ini, sekitar 80%-nya diakibatkan adanya gangguan

pada alat keseimbangan di telinga dalam, sisanya dapat terjadi di sentral
(otak). Penyakit gangguan keseimbangan pada telinga banyak penyebabnya.
Salah satu gangguan keseimbangan yang sering terjadi, adalah rasa berputar
mendadak akibat perubahan posisi kepala (istilah medisnya: BPPV – Benign
Paroxysmal Positional Vertigo).

Penyebab BPPV pada usia muda (di bawah 50 tahun) biasanya akibat
benturan daerah kepala, dan infeksi sistem vestibuler perifer (gangguan pada
telinga bagian dalam). Di atas 50 tahun, biasanya akibat degenerasi
(pengurangan fungsi) dari sistem keseimbangan. Namun, hampir setengah
dari kasus BPPV tidak diketahui penyebabnya.

Pengobatannya, selain diberikan obat-obat untuk mengurangi rasa berputar

(vertigo), juga harus istirahat total sementara waktu. Selain itu, juga perlu
diberikan pengobatan latihan gerakan kepala dan badan, untuk mengadaptasi
keseimbangan dan mengurangi keluhan pusing.

The most important role of the general physician is in determining whether the patient has
a primary or secondary headache. Primary headaches
are those in which the headache and its features are
the disease itself, and secondary headaches are those
in which the headache is the result of another pathological process. Important examples of
primary headache
syndromes are migraine, tension-type headache and
cluster headache. Important examples of secondary
headaches are systemic infection, head injury, subarachnoid haemorrhage, vascular disorders
and brain
tumours
Migraine is a common, often familial, condition characterized by an episodic unilateral throbbing
headache
typically lasting up to 4 to 72 hours. The patient often
complains of photophobia, phonophobia and occasionally osmophobia, as well as nausea and
sometimes
vomiting. Patients with migraine often cannot bear to
do anything apart from lying quietly in a dark room
until their headache subsides. Exacerbation of pain
by movement is a prominent feature of migraine.
It is more common in young women and the headache
is often preceded by a visual aura with fortification
spectra or flashing lights or, less commonly, a sensory
aura with numbness and tingling in the fingers and/
or face.
The headache is thought to have a neurovascular
basis and to be related to the release of vasoactive substances by the trigeminovascular
system. The level of
serum 5-hydroxytryptamine (5-HT) rises with the prodromal symptoms and falls during the
headache. The
headache may follow abnormal electrical activity within
the cortex or ‘spreading depression’ and subsequent
brainstem activation leads to alterations in cranial vascular tone.
There are various subdivisions of migraine, although
migraine with aura (classical) and without aura (common) are the most frequently encountered
forms.

Basilar migraine
In basilar migraine, the brainstem aura causes symptoms
that arise fromdysfunction in the territory of the posterior
cerebral circulation, which supplies the brainstem, cerebellum and most of the occipital cortices.
The aura can
consist of bilateral visual symptoms, ataxia, dysarthria,
vertigo, limb paraesthesia and weakness. There may be
loss of consciousness before, during or after the onset
of headache, which often causes diagnostic confusion

2. patient with low mood

Feeling sad or upset is a normal part of the human condition; thus, a patient presenting with
emotional suffering does not necessarily warrant a psychiatric diagnosis
or require treatment. However, psychiatrists agree that
when patients present with a certain number of key depressive features, they are probably
suffering from some
form of psychopathology that will require, and usually
respond to, specific kinds of treatment.

-Biological (somatic) symptoms

In the past psychiatrists used to distinguish between
‘endogenous’ or ‘reactive’ depression. ‘Endogenous’
depression (also called somatic, melancholic, vital or biological depression) was assumed to
occur in the absence of an external environmental cause and have a
‘biological’ clinical picture. This is opposed to so-called
‘reactive’ or ‘neurotic’ depression where it is assumed
that the patient is, to some degree, understandably depressed, reacting to adverse
psychosocial circumstances.
However, most depression is a mixture of the two, and
an ‘understandable depression’ does not require any
less treatment than a ‘spontaneous depression’. ‘Biological’ symptoms are still important to
enquire about as if
present they suggest a more severe depression; however,
they are no longer viewed as providing information on
aetiology.

-Marked loss of appetite with weight loss

Although some depressed patients have an increased appetite and turn to ‘comfort eating’, only
a dramatic
reduction in appetite with weight loss (5% of body
weight in last month) is regarded as a biological symptom. Note that the reversed biological
features of overeating and oversleeping are sometimes referred to as
atypical depressive symptoms.

3. The patient needs to be reassured that there are no secondary causes of the headache and
that migraine is
essentially an inherited tendency to headache caused
by a patient’s genes that cannot be cured, but can be
modified and controlled. The avoidance of any precipitating lifestyle factors (e.g. particular food
types, stress,
sleep deprivation, dehydration, too much sleep) may be
helpful. For patients using oral contraceptives/HRT and
who have migraine with aura, there is an increased incidence of stroke. The risk is especially
high in smokers
with aura. In these patients the hormone treatment
should be stopped.
During an attack
In the stepped model of migraine care, assuming there
are no contraindications, patients use simple analgesia
such as soluble aspirin 900 mg or paracetamol 1000 mg
with an antiemetic (e.g. domperidone) to allow ingestion of the other drugs. Other NSAIDs can
also be useful, but adequate doses must be given. Gastrointestinal
side-effects such as dyspepsia may be limiting. Patients
should avoid the regular use of codeine because of the
risk of induction of a chronic ‘analgesic’ headache.
More severe, or refractory, attacks may be terminated
by the use of 5-HT agonists (e.g. sumatriptan, naratriptan, zolmitriptan, rizatriptan, eletriptan).
There are now
preparations that can be given subcutaneously or
nasally which bypass the need for gastric absorption.
They may have different rapidity and duration of
action, which should dictate choice in individual
patients. Ergotamine is still used for acute attacks, but relatively infrequently because of liability
to side-effects.
Prophylaxis
For frequent and severe attacks that occur more than
twice per month, daily treatment for 6 months or more
may be required to prevent headaches. Medications
include:
• propranolol (beta-adrenergic receptor blocker)
• amitriptyline (tricyclic agent)
• pizotifen (5-HT antagonist)
• sodium valproate or topiramate (anticonvulsants)
• verapamil (calcium antagonist)
• methysergide (5-HT antagonist): rarely used now
because it can cause retroperitoneal fibrosis.
HINTS AND TIPS
In patients with ‘medication overuse’ headache,
preventative medications are unlikely to be effective
until the regular analgesic use has been curtailed.

4. Anxiety/obsessive-compulsive
phenomena
Obsessive-compulsive and anxiety symptoms (freefloating anxiety, panic attacks, phobias, ruminatory
thoughts) need not be the presenting complaint to be
present to a clinically significant degree. These symptoms are common to many psychiatric disorders and,
if not specifically asked patients may fail to mention

Fig. 1.2 Typical questions used to elicit specific

psychiatric
symptoms
Questions used to elicit . . . Chapter/page
Suicidal ideas Ch. 6, p. 46

Depressive symptoms Ch. 7, p. 53

Mania/hypomania Ch. 8, p. 62

Delusions Ch. 9, p. 75
 Hallucinations Ch. 9, p. 74

Symptoms of anxiety Ch. 10, p. 82

Obsessions and compulsions Ch. 11, p. 85

Somatoform disorders Ch. 13, p. 98

Memory and cognition Ch. 14, p. 103

Problem drinking Ch. 15, p. 121

Symptoms of anorexia and bulimia Ch. 17, p. 128

Symptoms of insomnia Ch. 30, p. 203

Psychiatric assessment and diagnosis

6
them. Also record stress reactions, dissociative symptoms, and depersonalization and derealization here
(see Ch. 12). Figure 1.2 can direct you to typical questions that may be used to elicit obsessive-compulsive
and anxiety symptoms.
HINTS AND TIPS
Depression and obsessive-compulsive symptoms often
coexist (>20%) with onset before, simultaneously or
after the onset of depression. You may find it useful to
have a set of screening questions ready to use

Perception
Hallucinations are often mentioned during the history
However, this is not always the case, so it is important
that you specifically enquire about abnormal perceptual
experiences (perceptual abnormalities are defined and
classified on p. 66, Ch. 9). If patients admit to problems
with perception, it is important to ascertain:
• Whether the abnormal perceptions are genuine hallucinations, pseudohallucinations, illusions, or intrusive thoughts.
• From which sensory modality the hallucinations appear to arise (i.e. are they auditory, visual, olfactory,
gustatory or somatic hallucinations – see p. 67).
• Whether auditory hallucinations are elementary or
complex. If complex, are they experienced in the
first person (audible thoughts, thought echo), second person (critical, persecutory, complimentary or
command hallucinations) or third person (voices
arguing or discussing the patient, or giving arunning
commentary)?

Agoraphobia
Agoraphobia literally means ‘fear of the marketplace’, i.e.
fear of public places. In psychiatry today, it has a wider
meaning that also includes a fear of entering crowded
spaces (shops,trains,buses,elevators)whereanimmediate
escapeisdifficultorinwhichhelpmightnotbe availablein
the event of having apanic attack. At the worst extreme, patients may become housebound or refuse to leave the
house unless accompanied by a close friend or relative.
There is a close relationship between agoraphobia
and panic disorder that occurs when patients develop
a fear of being in a place from where escape would be
difficult in the event of having a panic attack. In fact,
studies have shown that in a clinical setting, up to
95% of patients presenting with agoraphobia have a
current or past diagnosis of panic disorder. Therefore,
in the ICD-10 you can code agoraphobia as occurring
with or without panic disorder.
Social phobia
Patients with social phobia fear social situations where
they might be exposed to scrutiny by others that might
lead to humiliation or embarrassment. This fear might
be limited to an isolated fear (e.g. public speaking, eating in public, fear of vomiting, or interacting with the
opposite sex) or may involve almost all social activities
outside the home.
Specific phobia
Specific (simple) phobias are restricted to clearly specific and discernible objects or situations (other than
those covered in agoraphobia and social phobia). Examples from adult psychiatric samples in order of decreasing prevalence
include:
• Situational: specific situations, e.g. public transportation, flying, driving, tunnels, bridges, elevators.
• Natural environment: heights, storms, water,
darkness.
• Blood–injection–injury: seeing blood or an injury,
fear of needles or an invasive medical procedure.
• Animal: animals or insects, e.g. spiders, dogs, mice.
• Other: fear of choking or vomiting, contracting an illness (e.g. HIV), children’s fear of costumed characters.

5. Biological (somatic) symptoms

In the past psychiatrists used to distinguish between
‘endogenous’ or ‘reactive’ depression. ‘Endogenous’
depression (also called somatic, melancholic, vital or biological depression) was assumed to
occur in the absence of an external environmental cause and have a
‘biological’ clinical picture. This is opposed to so-called
‘reactive’ or ‘neurotic’ depression where it is assumed
that the patient is, to some degree, understandably depressed, reacting to adverse
psychosocial circumstances.
However, most depression is a mixture of the two, and
an ‘understandable depression’ does not require any
less treatment than a ‘spontaneous depression’. ‘Biological’ symptoms are still important to
enquire about as if
present they suggest a more severe depression; however,
they are no longer viewed as providing information on
aetiology.

-Loss of libido
Sensitive questioning will often reveal a reduction in sex
drive that may lead to guilt when the sufferer feels unable to satisfy their partner..

LO
 1. Sakit kepala berkepanjangan juga disebut dengan sakit kepala kronis. Kondisi ini
ditandai dengan sakit kepala yang berlangsung minimal 15 menit dalam satu
bulan, dan terjadi selama tiga bulan berturut-turut. Kondisi ini dikelompokkan
berdasarkan penyebabnya. Sakit kepala berkepanjangan ini dapat
dikelompokkan menjadi dua jenis, yaitu:

 Sakit kepala kronis primer, yaitu sakit kepala murni sebagai tanda adanya
penyakit lain yang mendasari terjadinya sakit kepala.

 Sakit kepala non-primer, yaitu sakit kepala kronis yang terjadi akibat dari
penyakit lain yang mendasari.

Banyak kasus sakit kepala kronis primer yang tidak diketahui penyebabnya. Namun
pada sakit kepala kronis non-primer, memiliki beberapa kemungkinan penyebab. Antara
lain peradangan, infeksi, maupun gangguan pembuluh darah pada otak, cedera, tumor
otak, dan gangguan tekanan pada otak. Berikut ini merupakan beberapa penyakit yang
dapat memicu terjadinya sakit kepala kronis non-primer, antara lain:

 Migrain Kronis

Migrain ini terjadi pada seseorang yang pernah mengalami migrain sebelumnya. Gejala
dapat berupa sakit pada satu atau dua sisi kepala, kondisi ini dapat mengakibatkan
sakit yang begitu luar biasa dengan sensasi berdenyut pada sisi kepala yang terkena
migrain.

 Hemicrania Continua

Kondisi ini ditandai dengan sakit kepala di salah satu sisi kepala, terjadi setiap hari dan
secara terus-menerus dengan intensitas yang naik turun. Kondisi ini bisa diiringi dengan
gejala mata merah atau berair pada salah satu sisi yang terasa sakit, hidung berair dan
tersumbat, serta menurunnya kelopak mata atau pembesaran pupil mata.

 Sakit Kepala yang Baru Timbul dan Terjadi Secara Terus-menerus

Sakit kepala jenis ini biasa muncul secara mendadak. Dengan gejala sakit kepala yang
menekan atau kepala terasa mengencang. Rasa sakitnya mulai dari ringan hingga
menengah, tanpa dipengaruhi oleh aktivitas tertentu.

 Sakit Kepala Akibat Tekanan di Dalam Rongga Kepala

Kondisi ini dapat dipicu karena adanya tumor otak, kista, atau volume cairan otak yang
meningkat, sehingga tekanan di kepala pun ikut meningkat. Gejala yang timbul dapat
berupa sakit kepala yang muncul secara tiba-tiba, serta diiringi dengan gangguan saraf
lain seperti muntah.
Kamu bisa mengikuti beberapa cara di bawah ini untuk menangani timbulnya pusing
berkepanjangan yang kamu alami. Penanganan dapat berupa:

 Minimalisir stres.

 Batasi aktivitas fisik yang berat dan jangan terlalu lelah.

 Beristirahat dengan cukup, dan atur waktu tidur selama 7-9 jam setiap malam.

 Minum cukup air putih 2-3 liter sehari untuk mencegah dehidrasi.

 Hindari konsumsi kafein, alkohol, dan rokok.

 Makan secara teratur, karena terlambat makan dapat memicu terjadinya pusing.

 Berolahraga secara rutin.

 Hindari paparan sinar matahari terik yang berlebihan.