Professional Documents
Culture Documents
P
Mood disorders S
Y Substance
C induced
“organic”
H mental
“Functional” O disorders
disorders S Delirium
Schizophrenia
“spectrum” I Dementia
disorders S Amnestic d/o
SKIZOFRENIA
SKIZOFRENIA
GGN BERAT DLM BIDANG : PIKIRAN, PERASAAN, PERBUATAN,
PERSEPSI, KEINGINAN, DORONGAN KEHENDAK &
PENGENDALIAN
• Schizophrenia is defined by
– a group of characteristic positive and negative symptoms
– deterioration in social, occupational, or interpersonal
relationships
– continuous signs of the disturbance for at least 1 months
History
• Emil Kraepelin: This illness develops relatively early in life, and
its course is likely deteriorating and chronic; deterioration
reminded dementia („Dementia praecox“), but was not
followed by any organic changes of the brain, detectable at that
time.
• Eugen Bleuler: He renamed Kraepelin’s dementia praecox as
schizophrenia (1911); he recognized the cognitive impairment
in this illness, which he named as a „splitting“ of mind.
• Kurt Schneider: He emphasized the role of psychotic symptoms,
as hallucinations, delusions and gave them the privilege of „the
first rank symptoms” even in the concept of the diagnosis of
schizophrenia.
4 A (Bleuler)
• Bleuler maintained, that for the diagnosis of schizophrenia are
most important the following four fundamental symptoms:
– affective blunting
– disturbance of association (fragmented thinking)
– autism
– ambivalence (fragmented emotional response)
• These groups of symptoms, are called „four A’ s” and Bleuler
thought, that they are „primary” for this diagnosis.
• The other known symptoms, hallucinations, delusions, which are
appearing in schizophrenia very often also, he used to call as a
“secondary symptoms”, because they could be seen in any other
psychotic disease, which are caused by quite different factors —
from intoxication to infection or other disease entities.
Course of Illness
Gejala Gejala
Positif Negatif
Interpersonal
Waham Perawatan diri
Ekspresi datar
Halusinasi
Kekacauan Kehilangan minat
pembicaraan ide
Kontak Katatonia motivasi
Sosial Pekerjaan
Gejala
Kognitif Gejala
Gangguan Perasaan
Pemanfaatan
Konsentrasi
Ketidaknyamanan
Kesejahteraan
Putus Asa
akses
Memori psikologis
Pikiran Bunuh Diri
Kemampuan
Perencanaan
Negative Positive
Alogia Hallucinations
Affective flattening Delusions
Avolition-apathy Bizarre behaviour
Anhedonia-asociality Positive formal thought
disorder
Attentional impairment
Andreasen N.C., Roy M.-A., Flaum M.: Positive and negative symptoms. In: Schizophrenia,
Hirsch S.R. and Weinberger D.R., eds., Blackwell Science, pp. 28-45, 1995
I. SKIZOFRENIA PARANOID
• PALING SERING DITEMUKAN
• PEDOMAN DIAGNOSTIK
1. PED DIAGNOSTIK UMUM
2. HALUSINASI DAN / ATAU WAHAM HARUS MENONJOL :
a. SUARA MENGANCAM / MEMERINTAH, BUNYI
PLUIT, MENDENGUNG ATAU TAWA
b. PEMBAUAN / PENGECAP RASA. PERABAAN YG
BERSIFAT SEKSUAL, JARANG VISUAL
c. WAHAM HAMPIR SETIAP JENIS, TETAPI PALING
KHAS ADALAH DIKENDALIKAN, DIPENGARUHI,
PASSIVITY DAN DIKEJAR-KEJAR
II. SKIZOFRENIA HEBEFRENIK
• ONSET BIASA PD UMUR < MUDA
• PEDOMAN DIAGNOSTIK
1. PED DIAGNOSTIK UMUM
2. DIAGNOSTIK PERTAMA KALI PD USIA REMAJA ATAU DEWASA
MUDA (15-25 THN)
3. KEPRIBADIAN PREMORBID CIRI KHAS : PEMALU, SENANG
MENYENDIRI
4. UTK DIAGNOSIS DIPERLUKAN PENGAMATAN KONTINU 2-3 BLN
a. MANNERISME, CENDERUNG MENYENDIRI, HAMPA
TUJUAN / PERASAAN
b. AFEK DANGKAL & TDK WAJAR, CEKIKIKAN, RASA
PUAS DIRI, SENYUM SENDIRI, TAWA
MENYERINGAI, UNGKAPAN KATA DI ULANG-ULANG
c. PROSE PIKIR DISORGANISASI, PEMBICARAAN TDK
MENENTU, INKOHERENSI
5. DORONGAN KEHENDAK HILANG, TDK ADA MINAT, KADANG
INGIN BERBUAT SESUATU TAPI SEGERA DITINGGALKAN,
PREOKUPASI YG DANGKAL DGN TEMA ANEH → SULIT
MEMAHAMI JALAN PIKIRAN
III. SKIZOFRENIA KATATONIK
• YG MENONJOL GAMBARAN PSIKOMOTOR : HIPEKINESIS,
STUPOR, OTOMATISME & NEGATIVISME
• PEDOMAN DIAGNOSTIK
1. PED DIAGNOSTIK UMUM
2. > 1 PERILAKU MENDOMINASI GAMBARAN KLINISNYA
a. STUPOR ATAU MUTISME
b. GADUH GELISAH
c. POSTURING (TDK WAJAR & ANEH)
d. NEGATIVISME
e. RIGIDITAS
f. FLEKSIBILITAS CEREA
g. GEJALA LAIN : COMMAND AUTOMATISM,
VERBIGERASI, EKOLALI & EKOPRAKSI
IV. SKIZOFRENIA SIMPLEKS
• SULIT DIBUAT
• PEDOMAN DIAGNOSTIK
GEJALA KRONIK PROGRESIF DARI :
a. GEJALA NEGATIF SKIZOFRENIA
RESIDUAL TANPA DIDAHULUI GEJALA
POSITIF
b. PERUBAHAN PERILAKU PRIBADI,
HILANG MINAT, TDK BERBUAT
SESUATU, TANPA TUJUAN HIDUP &
PENARIKAN DIRI SECARA SOSIAL
Etiology of Schizophrenia
“1-Dopamine adjusts
the volume—Blocked
by antipsychotics
2-Acetycholine and
GABA filter signal
from noise
3-Glutamate imprints
new memories”
30
Robert Freedman
Psychosocial Factors
• Expressed emotion
• Stressful life events
• Low socioeconomic class
• Limited social network
Treatment Goal of Schizophrenia
Productivity
Subjective (school, earning
money or being a
Quality of
volunterary
Life Recovery worker) GAF 65
Harding, dkk 1987
Symtoms
(Free of
symtoms &
without
medicine,2
yrs)
Lieberman, et
all, 2002
Goals of Pharmacotherapy for Schizophrenia
Recovery
Remission
Symtoms & function
Cognitive & Insight Functionality
Remisssion
(symtoms mild or less for
6 months)
Resolusion
(symtoms no time limit)
Response
Acute Episode
The Continuum of Care
Efficacy
Positive symptom relief Negative symptom relief
Hostility, aggression Improve mood and
Smooth IM to PO transition depressive symptoms R
Cognitive improvement e
Control
Behavior
Relapse Prevention
c
(agitation)
1-3 days 7-14 days 6+ months
o
Acute dystonia EPS TD
v
Sedation
Orthostasis
Drug-drug interactions Hyperprolactinemia e
QTc prolongation Weight gain
QTc prolongation Hyperglycemia r
QTc prolongation
y
Safety
Treatment of Schizophrenia
• The acute psychotic schizophrenic patients will respond usually
to antipsychotic medication.
• According to current consensus we use in the first line therapy
the newer atypical antipsychotics, because their use is not
complicated by appearance of extrapyramidal side-effects, or
these are much lower than with classical antipsychotics.
Poor Male
premorbid sex
Early age of
adjustment onset
Modifiable factors
44 Robinson et al. Am J Psychiatry 2004;161:473–479; Emsley et al. J Clin Psychiatry 2006;67:1707–1712
Prognosis contd.
• Good outcome is associated with:
– Female
– Older age of onset
– Married
– Higher SEG
– Living in a developing (as opposed to developed) country
– Good premorbid personality
– No previous psych history
– Good education and employment record
– Acute onset, affective symptoms, good compliance with meds
Prognosis contd.
• Some of the predictors of outcome are the
consequence of a less severe illness
47
48
GANGGUAN SKIZO AFEKTIF
• TERDPT GGN AFEKTIF & GEJALA SKIZOFRENIA PD SAAT
BERSAMAAN
• PEDOMAN DIAGNOSTIK UMUM :
1. TERDPT GEJALA2 SKIZOFRENIA & GGN
AFEKTIF SAMA MENONJOL PD SAAT
BERSAMAAN
2. TDK BOLEH ADA GEJALA SKIZOFRENIA &
GGN AFEKTIF DLM EPISODE PENYAKIT YG
TERPISAH
3. BILA SEORANG SKIZOFRENIA MENUNJUKKAN
GEJALA2 DEPRESIF SETELAH MENGALAMI
SUATU EPISODE PSIKOTIK DIBERI
DIAGNOSIS DEPRESI PASCA SKIZOFRENIA
I. GGN SKIZO AFEKTIF TIPE MANIK
PEDOMAN DIAGNOSTIK :
• PEDOMAN DIAGNOSTIK
1. PEDOMAN DIAGNOSTIK UMUM
2. HALUSINASI ATAU WAHAM YG BERUBAH DLM JENIS
& INTENSITASNYA
3. KEKALUTAN EMOSIONAL YG ANEKA RAGAM & LEBIH
SERING SENANG, SEDIH, CEMAS ATAU MARAH
4. GEJALA YG ANEKA RAGAM ITU TAK SATUPUN
SECARA CUKUP KONSISTEN DPT MEMENUHI KRITERIA
SKIZOFRENIA, EPISODE MANIK ATAU DEPRESIF
• PEDOMAN DIAGNOSTIK
1. MEMENUHI KRITERIA 1, 2, & 3 GGN
PSIKOTIK POLIMORFIK AKUT TANPA
GEJALA SKIZOFRENIA
2. DISERTAI GEJALA2 YG MEMENUHI
KRITERIA D/ SKIZOFRENIA YG SUDAH
HRS ADA UTK SEBAGIAN BESAR WAKTU
SEJAK MUNCULNYA GAMBARAN KLINIS
PSIKOSIS ITU SECARA JELAS.
3. JIKA GEJALA SKIZOFRENIA MENETAP
LEBIH DARI 1 BLN MAKA DIAGNOSIS HRS
DIRUBAH → SKIZOFRENIA
III. GGN PSIKOTIK LIR-SKIZOFRENIA AKUT
• PEDOMAN DIAGNOSTIK
1. PEDOMAN DIAGNOSTIK UMUM
2. GEJALA2 YG MEMENUHI KRITERIA UTK SKIZOFRENIA
YG HRS SDH ADA UTK SEBAGIAN BESAR WAKTU SEJAK
MUNCULNYA GAMBARAN PSIKOTIK YG JELAS
3. TAK ADA ATAU KALAU ADA GEJALA LAIN SANGAT
MINIM RAGAMNYA, SANGAT SEMENTARA &
INTENSITASNYA RINGAN
4. JIKA GEJALA SKIZOFRENIA MENETAP LEBIH DARI 1
BLN MAKA DIAGNOSIS HRS DIRUBAH → SKIZOFRENIA
• UNTUK D/ PASTI:
– ONSET GEJALA PSIKOTIK HRS AKUT
– WAHAM & HALUSINASI HRS SUDAH ADA DLM SEBAGIAN
BESAR WKT SEJAK BERKEMBANGNYA KEADAAN PSIKOTIK
YG JELAS
– TDK MEMENUHI KRITERIA SKIZOFRENIA MAUPUN
PSIKOTIK POLIMORFIK AKUT
• KALAU WAHAM MENETAP > 3 BLN GGN WAHAM
MENETAP, KALAU HALUSINASI MENETAP > 3 BLN
GGN PSKOTIK NON-ORGANIK LAINNYA