CASE BASED DISCUSSION

PSIKOTIK

Counselor
dr. Sabar Siregar , Sp. KJ

Department of Mental Health Sciences

Mental Hospital Prof. Dr. Soerojo Magelang
Period August 28 - September 29, 2017
Faculty of Medicine Christiany University Indonesia
Magelang
 PATIENT IDENTITY
2

Name : Mrs. S
Age : 51 years old
Sex : Female
Address : Wates Tengah, Magelang
Ethnic : Javanese
Religion : Moslem
Education : Elementary School
Occupation : Housewife
Marital status : Married
Date of exam : 1st September 2017

12/04/2017
 RELATIVES IDENTITY
Name : Mrs. NS
Sex : Female
Age : 30 years old
Address :Wates Tengah, Magelang
Ethnic : Javanese
Religion : Moslem
Occupation : Housewife
Marital Status : Married
Relation : Dauughter
MAIN COMPLAINT

Patient has bizzare

behavoiur
 HISTORY OF
PRESENT ILLNESS
 ALLOANAMNESIS
6

June 17th 2017

June3rd 2017
The complaint become worsen
patient mutter and
The frequency of eat, drink, and take a
talking alone, August 3rd September 2017
bath are increasing
wandering around, taken to ER because
did some unusual activity such as clean
easy to be offended she got angry with no cause and
the house in the midnight
and did not sleep destroyed things at home since a day
shopped the stuff that she already had
she usually saw an ago .
in her house, had a courage to lie, and
unknown black man in threaten her family that she wants to
wearing exaggerate make up that she
her kitchen and in the commit suicide
never did before.
living room.
she usually saw an unknown black man
in her kitchen and in the living room.

The patients husband said that she is an introvert person.

ALLOANAMNESIS
Symptomps :
bizzaconfuse
Two months
d to do
She had ever ago : she did
something,
hospitalized for 5 not want to
like a
times (2011, 2012, take her
daydreaming, These symptomps
2013 ,2014 ,2015) medicines
and threw a always seem if
with the same because she
glass. Wake patient didnt took
symptomps for a felt better and
up in the the medicines
month but still remembered
midnight to regularly
had been going about her debt
clean up the
from 2011 until in the past and
room and
now. her husband
walking
was cheating.
around her
house
HISTORY OF PAST ILLNESS

Head injury (-)

Hypertension (-)
General medical history Convulsion (-)
High fever (-)
Allergy (-)
Diabetes Mellitus (-)

Drugs, alcohol abuse, and Drugs consumption (-)

smoking history Alcohol consumption (-)
Smoking habit (-)
PERSONAL HISTORY
1 . P R E N A TA L A N D P E R I N A TA L H I S T O R Y

2 . E A R LY C H I L D H O O D P H A S E

3 . I N T E R M E D I AT E C H I L D H O O D

4 . L AT E C H I L D H O O D

5 . A D U LT H O O D
PRENATAL AND PERINATAL
1. Patients is the third child from 6 siblings
2. Healthy maternal condition during pregnancy and childbirth
3. Born in a clinic assisted by midwife normally, aterm, and immediately cried at birth
4. There is no valid data about his weight and length birth, APGAR score and
immunization status
EARLY CHILDHOOD (0-3 YEARS OLD)
1. There were no valid data about her psychomotor, when the patient started began to lift head, roll over,
hold object, sitting, standing, walking, and running.
2. There were no valid data about her psychosocial when the patient started smiling, while seeing
another faces when patient first laugh of playing claps with other people and started by noise.
3. There were no valid data about her reasoning, when the patient started to have a sucking relax,
started to labelling a spesific name for object, differetiated object on its function by her perception.
4. There were no valid data about her emotion, while the patient frightened by a stranger, started to
show jealously or competitive towards other.
5. This phase leads to basic virtue of hope. (trust vs mistrust) skills and ability ( autonomy vs shame and
doubt) .
MIDDLE CHILDHOOD (3 - 11 YEARS)
1. There were no valid data about her psychomotor, when the patient began to run easily,
with one foot without support.
2. There were no valid data about her psychososial, when the patient knew the difference
between boys and girls and being able to control the conduct behaviour.
3. There were no valid data about her reasoning, when the patient able to manage her
personal, such us choosing clothes and arrange a daily schedule.
4. There were no valid data about her emotion, when the patient differentiated procced and
happy, understand two complex emotion such us proud.
5. There were no valid data about her communication with other. This phase leads to bassic
virtue of purpose ( initiate vs guilt) and competency ( industry vs inferiority)
LATE CHILDHOOD (PUBERTY THROUGH ADOLESCENCE)

There were no valid data when patient think more logically, learning to plan a
head ( reasoning), greater ability to talk about thought and feeding( emotion
and communication), so physical activity (pscychomotor).
This is the major stated of development when the child learned the rules.
She will re-examine her identity and examine find to find out who she is.
This phase leads to basic virtue of fidelity ( ego of identity vs role
 ADULTHOOD
Educational history : patient graduated from elementary school
Occupational history: She ever worked as housemaid in 2011 to 2012, then
she resigned because of her disease. In 2017 she back to work again as a
housemaid in the same landlord but suddenly she resigned again because her
disease relapsed.
Social history : she has good relation in her neighborhood
Marital history : patient has married and she has two daughter.
ADULTHOOD
Religion history :
Patient is a moslem and she often to pray.
She is a moslem and used to always pray 5 times/day.
Her daughter said since she was sick, she still remember to pray 5 times/day
Military history : there is no military history.
Sexual history : patient realizes that she is a woman and has been dressing up
and acting as a woman. She is attracted to men.
Current living situation : She lives with her husband. Her husband work as a
labor, he is a breadwinner in his family.
ERIKSONS STAGES OF PSYCHOSOCIAL
DEVELOPMENT
Stage Basic Conflict Important Events
Infancy Trust vs mistrust Feeding
(birth to 18 months)
Early childhood Autonomy vs shame and doubt Toilet training
(2-3 years)
Preschool Initiative vs guilt Exploration
(3-5 years)
School age Industry vs inferiority School
(6-11 years)
Adolescence Identity vs role confusion Social relationships
(12-18 years)
Young Adulthood Intimacy vs isolation Relationship
(19-40 years)
Middle adulthood Generativity vs stagnation Work and parenthood
(40-65 years)
Maturity Ego integrity vs despair Reflection on life
(65- death)

Conclusion: no clear data

 FAMILY HISTORY
There was patients family members suffers from the same complaint or any other psychiatric
symptoms which is his grandfather.

Male

Female

Patient

Lives together

Died
Socio-Economic History
Economic Scale : Poor

Validity
Alloanamnesis : Valid Data
Autoanamnesis : Valid Data
PROGRESSION OF DISORDER
Symptoms

2011 2012 2013 2014 2015 2017

Role of Function
 PHYSICAL
EX AMINATION
PHYSICAL AND NEUROLOGICAL EXAMINATION
I. General situation
Awareness : Compos mentis (GCS: 15)
Nutrition Impression : Good
Blood pressure : 120/80 mmHg
Heart Rate : 82 x / minute
Respiratory Rate : 20 x / minute
Temperature : 36.7oC
Weight/ height : 48 kg / 158 cm (BMI: 48 / (1.58) 2 = 19.27 kg / m2)
GENERALIZED STATUS
GENERALIZED STATUS
 NEUROLOGICAL STATUS
1. GCS : 15 (E4 M6 V5)
2. Cranial Nerve Examination I XII : No abnormalities found
3. Examination Meningeal stimulant :.
Stiff neck : (-)
Brudzinski I : (-)
Brudzinski II : (-)
Laseque : (-)
Kernig : (-)
4. Physiological Reflex Examination
Biseps : ++/++
Triceps : ++/++
Patella : ++/++
Achilles : ++/++
NEUROLOGICAL STATUS
5. Motoric system:
Upper Limb: 5555/5555
Lower Limb: 5555/5555
6. Pathologic Reflex Examination :
Hoffman Tromner : -/-
Babinski : -/-
Chaddock : -/-
Schaefer : -/-
Oppenheim : -/-
Gordon : -/-
7 Involuntary Movement : None
EX AMINATION OF
MENTAL STATUS
GENERAL DESCRIPTION
Appearance
A female appropriates to her age, completely clothed, enough self care

State of Consciousness
Neurologic : Compos Mentis
Psychologic : Clear
Physic contact
Presence,can be maintained, constant
GENERAL DESCRIPTION
Behaviour
Normoactive

Attitude
Cooperative

Impulse control
Self control : Enough
Patient response towards examination : Enough
GENERAL DESCRIPTION

Verbal
Quantity : Increase
Quality : Coherent
MOOD AND AFFECT
Mood

Happy

Affect

Elevated
Appropriate
PERCEPTUAL DISORDER

Hallucination Illusion
Auditory (+) Auditory (-)
Visual (+) Visual (-)
Olfactory (+) Olfactory (-)
Gustatory (-) Gustatory (-)
Tactile (-)
Tactile (-)

Depersonalisation (-) Derealisation (-)

THOUGHTS

Form of Thought of
thought content
Non Realistic Thought of withdrawal
Delusion of reference
THOUGHT OF PROCESS
Quantity Quality
Logorrhea Coherent
Blocking
Incoherent
Remming Confabulation
Mutisme Circumstantially
Talkative Tangentially
Normal Flight of idea
Neologism
Irrelevant answer
Loose of association
Echolaly
Verbigeration
 INSIGHT
Insight
Impaire insight (+) stage I
Intelectual Insight
True Insight
SENSORIUM AND COGNITION
1. Education level : Good
2. General knowledge : Good
3. Concentration : Good
4. Orientation
Time : Good
Place : Good
People : Good
Situation : Good
5. Memory
Long-term : Good
Medium medium : Good
Short-term : Good
6. Immediate period : Good
7. Abstract thoughts : Good
8. Creative talent : None
9. Self-help : Good
REALITY TESTING ABILITY AND ADJUSTMENT

Reality Testing
Adjustment
Ability
Good Good
 RESUME
Mrs. S was taken to ER RSJ Prof. Dr. Soerojo Magelang by her husband
and her daughter because she got angry with no cause and destroyed
things at home since two days before taken to the hospital. Two
months before, the patient mutter and talking alone, wandering
around, easy to be offended and did not sleep, she could eat, drink and
take bath by herself in so many times, clean the house in the midnight,
always shopped the stuff that she already had in her house, had a
courage to lie, and wearing exaggerate make up. She had been
hospitalized for 5 times with the same symptomps because she did
not take her medicines regularly and when he remembered about her
debt in the past and her husband was cheating.
RESUME
Based of examination of mental status
Impairment (Alloanamnesis)
Speech Increase, coherent
Mood Elevated
Didnt need sleep
Affect Inappropriate
Perception : : Hallucinations (+)
Auditory
Visual
The frequency of : eat
Olfactory ,drink and take bath are
Thought of flight of idea, coherent, talkactive increasing
process
Thought of Thought of withdrawal, delusion of reference
content
Form of thought non realistic
Insight Impaired Insight (Stage I)
 SYMPTOMS ON PATIENT
Psychic attention and contact
Behavior
Mood
Affect
Perception (hallucinations)
Thought of process
Thought of content:
o Though of withdrawal
o Delusion of reference
Forms of thought
Insight
: easy to attach and easy to maintain
: normoactive
: Happy
: elevated, appropriate
: Auditory, visual, olfactory
:flight of idea and coherent
: non-realistic.
: impaired insight.
 D I A G N O S T I C F O R M U L AT I O N

SYNDROME :
Schizophrenia syndrome Paranoid Syndrome Maniac Syndrome

Auditory hallucinations Auditory hallucinations Mood : happy

Visual hallucinations
Olfactory hallucination
Though of withdrawal
Delusion of references
Visual hallucination
Olfactory
hallucinations
Delusion of reference
Affect : Elevated
Thought of process :
flight of idea, talkactive
Full of energy and did
not sleep
Exaggerate to shop
and make up

40
DIFFERENTIAL DIAGNOSES
(DIAGNOSIS GANGGUAN JIWA PPDGJ-III)

Schizophrenia Paranoid ( F20.0)

Recurrent Depressive Disorder, current Severe Episode without
Psychotic Symptoms (F33.2. Gangguan Depresif Berulang, Episode Kini
Berat tanpa Gejala Psikotik)
Another Anxiety Disorder (F41 Gangguan Anxietas Lainnya)
Generalized Anxiety Disorder (F41.1 Gangguan Cemas Menyeluruh)
Mixed Anxiety and Depressed Disorder (F41.2 Gangguan Campuran
Anxietas dan Depresi )

41
 DIAGNOSIS
(DIAGNOSIS GANGGUAN JIWA PPDGJ -III)
42

F 32.- Episode Depresif (Depressive Episode)

Gejala Utama Fullfilled
a. Afek depresif
b. Kehilangan minat dan kegembiraan
c. Berkurangnya energi yang berujung meningkatnya keadaan mudah lelah dan
menurunnya aktivitas
Gejala Lainnya Fullfilled
a. Konsentrasi dan Perhatian kurang
b. Harga diri dan kepercayaan diri kurang
c. Gagasan tentang rasa bersalah dan tidak berguna
d. Pandangan masa depan yang suram dan pesimistis
e. Gagasan atau perbuatan membahayakan diri atau bunuh diri
f. Tidur terganggu
g. Nafsu makan berkurang
Diperlukan masa sekurang-kurangnya 2 minggu untuk penegakan diagnosis, akan tetapi periodeFullfilled
lebih pendek dapat dibenarkan jika gejala luar biasa beratnya dan berlangsung cepat
DIFFERENTIAL DIAGNOSES
(DIAGNOSIS GANGGUAN JIWA PPDGJ-III

F32.2 Episode Depresif Berat tanpa Gejala Psikotik (Severe Depressive Episode without Psychotic
Symptoms)
Semua 3 gejala utama depresi harus ada Fullfilled
Ditambah sekurang-kurangya 4 dari gejala lainnya, dan beberapa diantaranya harus Fullfilled
berintensitas berat
Bila ada gejala penting (misalnya agitasi atau retardasi psikomotor) yang mencolok, maka Fullfilled
pasien mungkin tidak mau atau tidak mampu untuk melaporkan banyak gejalanya secara
rinci
Episode depresif biasanya harus berlangsung sekurang-kurangnya 2 minggu, akan tetapi jika Fullfilled
gejala amat berat dan beronset sangat cepat, maka masih dibenarkan untuk menegakkan
diagnosis dalam kurun waktu kurang dari 2 minggu
Sangat tidak mungkin pasien akan mampu meneruskan kegiatan social, pekerjaan, atau Fullfilled
urusan rumah tangga, kecuali pada taraf yang sangat terbatas.
43
DIFFERENTIAL DIAGNOSES
(DIAGNOSIS GANGGUAN JIWA PPDGJ-III
44

F33.2 Gangguan Depresif Berulang, Episode Kini Berat tanpa Gejala Psikotik
(Recurrent Depressive Disorder, current Severe Episode without Psychotic
Symptoms)
Kriteria untuk gangguan depresif berulang harus dipenuhi, danFullfilled
episode sekarang harus memenuhi kriteria untuk depresif
berat tanpa gejala psikotik
Sekurang-kurangnya dua episode telah berlangsung masing-Un-fullfilled
masing selama minimal 2 minggu dengan sela waktu beberapa
bulan tanpa gangguan afektif yang bermakna
DIFFERENTIAL DIAGNOSES
(DIAGNOSIS GANGGUAN JIWA PPDGJ-III

F41 Gangguan Anxietas Lainnya (Another Anxiety Disorder)

Manifestasi anxietas merupakan gejala utama dan tidak terbatas pada Fullfilled
situasi lingkungan tertentu saja

Dapat disertai gejala-gejala depresif dan obsesif, bahkan juga beberap Fullfilled
unsur dari anxietas fobik, asal saja jelas bersifat sekunder atau ringan
DIFFERENTIAL DIAGNOSES
(DIAGNOSIS GANGGUAN JIWA PPDGJ-III

F41.1 Gangguan Cemas Menyeluruh (Generalized Anxiety Disorder)

Penderita harus menunjukkan anxietas sebagai gejala primer yang berlangsung hampir setiap hari Fullfilled
untuk beberapa minggu sampai beberapa bulan, yang tidak terbatas atau hanya menonjol pada
keadaan situasi khusus tertentu saja (Sifatnya free floating atau mengambang)

Gejala-gejala tersebut biasanya mencakup unsur-unsur berikut : Fullfilled

a. Kecemasan (Khawatir akan nasib buruk, merasa seperti di ujung tanduk, sulit konsentrasi,
dsb.)
b. Ketegangan Motorik (Gelisah, sakit kepala, gemetaran, tidak dapat santai, dsb)
c. Overaktifitas otonomik (Kepala terasa ringan, berkeringat, jantung berdebar-debar, sesak
nafas, keluhan lambung, pusing, kepala, mulut kering, dsb)
DIFFERENTIAL DIAGNOSES
(DIAGNOSIS GANGGUAN JIWA PPDGJ-III

Pada anak-anak sering terlihat adanya kebutuhan berlebihan untuk ditenangkan Fullfilled
(reassurance) serta keluhan kelujan somatik berulang yang menonjol

Adanya gejala gejala lain yang sifatnya sementara (untuk beberapa hari), khususnya Fullfilled
depresi, tidak membatalkan diagnosis utama Gangguan anxietas menyeluruh, selama hal
tersebut tidak memenuhi kriteria lengkap dari episode depresif (F32.-), gangguan
anxietas fobik (F40.-), gangguan panic (F41.0), atau gangguan obsesif kompulsif (F42.-)
DIFFERENTIAL DIAGNOSES
(DIAGNOSIS GANGGUAN JIWA PPDGJ-III

F41.2 Gangguan Campuran Anxietas dan Depresi

Terdapat gejala-gejala anxietas maupun depresi, di mana masing-masing tidak menunjukkan Fullfilled
rangkaian gejala yang cukup berat untuk menegakkan diagnosis tersendiri. Untuk anxietas,
beberapa gejala otonomik harus ditemukan walupun tidak terus menerus, disamping rasa
cemas atau kekhawatiran berlebihan

Bila ditemukan anxietas berat disertai depresi yang lebih ringan, maka harus dipertimbangkan Fullfilled
kategori gangguan anxieas lainnya atau gangguan anxietas fobik.
DIFFERENTIAL DIAGNOSES
(DIAGNOSIS GANGGUAN JIWA PPDGJ-III

Bila ditemukan sindrom depresi dan anxietas yang cukup berat untuk mengakkan masing- Unfullfilled
masing diagnosis, maka kedua diagnosis tersebut harus dikemukakan, dan diagnosis gangguan
campuran tidak dapat digunakan. Jika karena sesuatu hal hanya dapat dikemukakan satu
diagnosis maka gangguan depresif harus diutamakan

Bila gejala-gejala tersebut berkaitan erat dengan stress kehidupan yang jelas, maka harus Unfullfilled
digunakan kategori F43.2 gangguan penyesuaian.
50

MULTIA XIAL
EVALUATION
 MULTIAXIAL EVALUATION
51

AXIS I
Skizoafektif Tipe Manik

AXIS II
Not yet diagnose

AXIS III
Not yet diagnose

AXIS IV
Economical problem

AXIS V
GAF 50-41 Serious symptoms, Severe disability
Problems Description

Organobiology No specific physical or disease disorders are found that affect the patient's
mental state.Presumably there is a neurotransmitter imbalance that requires
pharmacotherapy.

PROBLEM LIST
Psychopathology Found psychological disorders that require psychopharmacotherapy and
psychotherapy to improve mental endurance and adaptability..
Socialogic Found severe impairmentin social interaction, occupation and use of leisure
time.

52
 THERAPY
PL ANNING
53
02/02/2017
PLANNING MANAGEMENT

INPATIENT (HOSPITALIZATION)
The patient was rampage
Destroyed things at home
Exaggerate to shop
Did not sleep
Perceptual disorder (auditory, visual &
olfactory hallucination, thoughtof withdrawal,
delusion of references).
PSYCHOFARMACOLOGY

First management in Emergency Room:

1. Inj Diazepam 1 amp 10 mg/12 hours (IV)
2. nj haloperidol 1 amp 5 mg/ 12 hours (IM)
3. Lithium carbonate 400 mg tablet/12 hours (PO)
4. Check laboratorium (blood routine, electrolyte, glucose
serum)
 PSYCHOFARMACOLOGY
Responsive phase (target therapy is 50% decreased symptom:
1. Chlorpromazine 100 mg/12 hours P.O
2. Lithium carbonate 400 mg tablet/12 hours P.O

Remission phase ( The target therapy is 100% decreased symptoms):

1. Chlorpromazine 100 mg/12 hours P.O
2. Lithium carbonate 400 mg/tablet/12 hours P.O

Psychososial therapy:
1. Provide an opportunity for patient to realize that he was sick, so she can take medication regularly
2. Provide explanation to family (especially parents) to provide moral support & gave more attention to
support his recovery
 PSYCHOFARMACOLOGY

Recovery phase (the target therapy is 100% decrease symptoms & the patient can able
to living his life like before)
1. Effectively managing medication treatment each & everyday: the patient ought to obey
medication drugs consumption followed by regular control to polyclinic
2. Actively working with health care term to set goals for rehabilitation
3. Taking an active part in rehabilitation, including a healthy lifestyle, & learning ways
cope with everyday stress.
PSYCHOTHERAPY

Cognitive: explain that the symptoms of patient illness caused by

the patients way thingking in resolving her problems
Supportibe provide support & attention to the patient
59

PROGNOSIS
 PREMORBID
60

Family disturbance history no : Good

Marital status married : Good
Family support yes : Good
Economic status less : Bad
Stressor known : Good
Premorbid personality none : Good
 MORBID
61

Age onset mild age : Bad

Type of disease psychotic : Bad
Course of diseases chronic: Bad
Organic illness none : Good
Therapy response : Good
Drug compliance irregular : Bad
 PROGNOSIS
62

Quo ad vitam : Bonam

Quo ad functionam : Dubia ad bonam
Quo ad sanactionam : Dubia ad malam
63

GALLERY
 THANK
YOU

65

12/04/2017