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Kepaniteraan Klinik Ilmu Kedokteran Jiwa Fakultas Kedokteran Universitas Pelita Harapan Sanatorium Dharmawangsa Periode 15 April 2013 13 Mei 2013
PENDAHULUAN
Gangguan yang ditandai: 1/> gejala neurologis tidak dapat dijelaskan oleh gangguan neurologis atau medis + faktor psikologis Hysterical Neurosis (histeria)
Tidak spesifik, terlalu banyak maknanya tidak digunakan lagi
Dalam DSM-IV, gangguan konversi ini merupakan konsep tersisa yang paling mendekati konsep lama histeria.
Hustera (uterus): uterus yang berkeliaran ( wandering uterus)
Konversi?
1880s akhir: Freud dan Breuer
Memori yang berhubungan dengan trauma psikis inervasi somatik mind-to- body process
DSM-IV-TR vs ICD-10
ICD-10
ICD-10
DSM-IV-TR
Somatoform Disorder
Somatization disorder Undifferentiated Somatoform Disorder Conversion Disorder Pain Disorder Hypochondriasis Body Dysmorphic Disorder Somatoform Disorder Not Otherwise Specified
DEFINISI
DSM-IV-TR
Conversion Disorder involves unexplained symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition. Psychological factors are judged to be associated with the symptoms or deficits
Kaplan & Saddock 10th edition: A conversion reaction is a rather acute and temporary loss or alteration in motor or sensory functions that appears to stem from psychological issues (conflict)
EPIDEMIOLOGI
1% masyarakat umum 5 14% konsultasi ke psikiatri 5 25% pasien rawat jalan Lebih sering pada:
Wanita Populasi pedesaan Penduduk negara berkembang Sosioekonomi rendah Anggota militer yang pernah terpapar medan perang Pengetahuan medis yang rendah
ETIOLOGI (TEORI-TEORI)
Faktor Psikoanalitik
konflik alam bawah sadar yang tidak terselesaikan Represi konflik-konflik intrapsikik yang tidak disadari konversi dari kecemasan ke dalam gejala fisik
Faktor pembelajaran
Merasa mendapat secondary gain ingin mempertahankan gejalanya
Faktor Biologis
pencitraan otak: hipometabolisme pada daerah hemisfer otak yang dominan dan hipermetabolisme pada daerah hemisfer yang nondominan.
GEJALA KLINIS
Paralisis, buta, mutisme disertai dengan gejala depresi dan cemas
Gejala Sensorik
Anestesi dan parastesi tidak sesuai dengan penyakit saraf pusat maupun tepi menimbulkan ketulian, kebutaan, dan tunnel vision
gerakan abnormal, gangguan gaya berjalan (contohnya: astasia abasia), kelemahan dan paralisis tremor ritmik kasar, gerak koreoform, tik, dan menghentakhentak yang memburuk bila pasien mendapat perhatian.
Keuntungan sekunder
keuntungan nyata yang diperoleh pasien dengan menjadi sakit misalnya dibebaskan dari kewajiban kehidupan yang sulit, bimbingan yang tak akan didapatkannya dalam situasi normal, dsb.
La belle indifference
sikap angkuh yang tak sesuai terhadap gejala serius yang dialaminya. Pasien tampak tak peduli dengan hendaya berat yang dialaminya. Walaupun begitu, ada tidaknya la belle indifference bukan dasar penilaian yang akurat untuk menegakkan gangguan konversi.
KRITERIA DIAGNOSIS
DIAGNOSIS BANDING
Eksklusi penyakit neurologis, kondisi medis, dan substanceinduced (termasuk medikasi)
Multiple Sclerosis Penggunaan alkohol dan obat-obatan
Hipokondriasis
Preokupasi dengan 1 penyakit serius Conversion: fokus pada gejala yang ada ; la belle indifference
PERJALANAN PENYAKIT
semua gejala awal (90-100%) dari pasien dengan gangguan konversi membaik dalam waktu beberapa hari sampai kurang dari sebulan. 75% pasien tidak pernah mengalami gangguan ini lagi 25% mengalami episode tambahan saat stresor psikis muncul kembali
TATALAKSANA
Gejala merupakan suatu bentuk perlindungan pasien terhadap kecemasan akibat konflik intrapsikik Terapi non farmakologis
Sugesti yang kuat serta pendidikan yang empatik hubungan erat antara pikiran, otak, dan tubuh.
Psikoterapi Psikodinamik
Dapat membantu pasien memahami konflik intrapsikis dan simbolisasi
Indikasi:
Pemulihan fungsi pseudoneurologik Membedakan gangguan konversi dengan malingering Abreaksi gangguan stress pasca trauma Pemulihan memory akibat fugue psikogenik dan amnesia
Kontraindikasi:
Kontraindikasi absolut berupa riwayat alergi dan porfiria Infeksi atau sumbatan saluran pernapasan Gangguan fungsi jantung, liver dan renal yang berat Kecanduan barbiturate Hipotensi atau hipertensi yang significant Minimal 12 jam sesudah minum alkohol terakhir bila ada kecurigaan keracunan alkohol Pasien paranoid Pasien menolak prosedur
PROGNOSIS
Prognosis lebih baik antara lain onset yang akut, stresor yang teridentifikasi, durasi gejala singkat, level kecerdasan pasien, gejala kelumpuhan, gejala kebutaan. Semakin lama gejala gangguan konversi ini berjalan, maka semakin buruk juga prognosisnya. Sebanyak 25-50% pasien akan mempunyai gangguan neurologis ataupun kondisi non-psikiatrik lain yang akan mempengaruhi sistem persarafan di kemudian harinya.
He (unconsciously) realizes that he will never be able to see her again A component of guilt: patient came to USA to earn money to help his mother but could not fulfill this obligation because he became addicted to heroin No physiologic explanation for his blindness Patients seems to be unconcerned about it ( la belle indifference)
LA BELLE INDIFFERENCE: Inappropriate lack of concern about ones disability.
Conversion symptoms: physical disorder (result of psychological factors) Psychodynamic model: symptoms are consequence of emotional conflict, with the repression of conflict into the unconscious Late 1880s: Freud and Breuer hysterical symptoms resulted from intrusion of memories connected to psychical trauma into somatic innervation mid-to-body process = conversion
The following features can help in deciding whether idiopathic physical symptoms may have a psychiatric etiology:
The symptoms coexist with major psychiatric disorders such as depression or panic. The symptoms closely follow traumatic events. The symptoms lead to psychological gratification or secondary gain. The symptoms represent predictable personality traits (coping mechanisms). The symptoms become persistent, join a conglomerate of other symptoms, and convey such attitudes as overuse of medical services and dissatisfaction with medical care.
The behavioral theory attributes conversion disorder to faulty childhood learning, with the nonadaptive behavioral responses used for secondary gain and control of interpersonal relationships. The psychoanalytic theory, on the other hand, describes symptoms as compromise formations with primary gain of conflict resolution through partial expression of the conflict without conscious awareness of its significance. Some have suggested a strong relationship between childhood traumatization by sexual or physical abuse and a later propensity for conversion disorder. Other studies, however, do not confirm such an association.
Although psychological etiology is a requisite of DSM -IV diagnosis, it is often dif ficult to identify it early in treatment and may not reveal itself until extensive additional history is obtained. Screening methods for assessing trauma, dissociative experience, and posttraumatic stress disorder (PTSD) should be helpful in this process.
ICD-10 disosiatif (konversi) gangguan termasuk amnesia disosiatif, fugue disosiatif, stupor disosiatif, gangguan kesurupan dan gangguan disosiatif gerakan dan sensasi (kirakira setara dengan diagnosis gangguan DSM-IV-TR konversi). Terakhir, mencakup gangguan motorik disosiatif, kejang disosiatif, dan anestesi disosiatif dan kehilangan sensoris.
underlying neurologic diseases to also develop conversion symptoms that do not conform to anatomic or physiologic parameters . in the dif ferential diagnosis are other somatoform disorders such as somatization disorder, undif ferentiated somatoform disorder, and hypochondriasis, as well as factitious disorders and malingering. Somatization disorder is a chronic dis - order that includes many physical symptoms, such as pain in several areas, gas - trointestinal complaints, sexual symptoms, and a conversion symptom. In undif ferentiated somatoform disorder, one or more physical complaints, such as fatigue, gastrointestinal symptoms, or urinar y dif ficulties, are present that are not physiologic in nature. Hypochondriasis is a chronic fear of having a serious illness as a result of misinterpretation of bodily sensations. Factitious disorders involve the intentional production of physical or psychological symptoms in order to assume the sick role (primar y gain). Malingering involves the intentional pro - duction or exaggeration of symptoms motivated by external incentives (avoiding a jail sentence, militar y duty, or work , or obtaining financial compensation) (secondar y gain).