Skenario D Blok 16: Kelompok L6
Skenario D Blok 16: Kelompok L6
Skenario D Blok 16: Kelompok L6
SKENARIO D
BLOK 16
Kelompok L6
Anggota kelompok
2
Priska Pramuji
Selly Alyanti
Surya Gunawan
Andwi Putri Lika
Siti Hardiyanti Yarika
Franz Sinatra Yoga
Karolina Chandra
Nabila Pratiwi Mardhiah
Pratiara Syamir Fasa
Netta Lionora
Andana Haris Tutor : dr. Djunaidi, SpPD
Salahudin Alfayubi
kelompok enam
skenario
3
Mrs.Sorrowati was a forty five years old teacher who lived in the rural area.
About three months ago, she started a fight with her husband like they always did before. A couple of days
after the fight, she started to look gloomy. At times, she would be found in her room weeping. She often
woke up late in the morning, and more often sleep lately after her usual bedtime. She usually lay still
while observing the ceiling during her “not sleeping period”. She withdrew her hobby of singing and
dancing at the local wedding party. Instead, she locked herself in her room during the occurrence of the
party. She refused to communicate the problem of her concern. In fact, she was very quiet at anytime
during the day. At work, she always gave her student an assignment instead of teaching them.
About two months ago, it was noticeable that her weight had decreased. During a silent observation, her
mother caught her dispose her dishes which she brought to her room. When asked about this, she stated
that she no longer had the appetite and refused to eat further. She failed to fulfill her job to cook for the
household. Her mother then took her role in the kitchen. She also failed to attend to her job location, and
was given a warning note from her superior.
About a month ago, she looked more anxious. For every job she failed to do, she blamed herself for being
guilty. At morning, she would complain her fatigue and stated that she won’t make anything out the day.
At noon, she would complain her inability to do things straight. Ant the evening, she would complain her
failure to do anything useful that day once, her mother caught her trying to swallow a large quantity of
headache pills.
After a family discussion, it was agreed that she would be taken to see an herbalist, but after seeing no
progression towards remission, she was brought to the Psychiatric clinic by her mother and her husband.
A psychiatric examination was then performed by the attending psychiatrist.
kelompok enam
4
Premorbid history
Birth : spontaneous birth delivery, lead by doctor
Childhood . adolescene & adult : she was generally considered a nica, cheerful, and communicable person.
Previous mental disorder and organobiologic developmental history
About a year ago, she exhibited an odd behavior. Back then, she would talk to everybody about her intimate activity
and laughed out loud at each story. She also spent most of her wage on charity. She almost ever rested without
feeling exhausted. This condition was accounted for at least a month, after which she returned normal gradually.
There was no organobiologic developmental history attributable to present illness.
Family history
She was the third of seven siblings. Her parents treat their children as fair as possible, and their children were
generally happy with their parents. O mental disoreder was noted in her family. Her relationship with her sibling
was good, although at some times she would fight for her parents’ affection
Education history
She was quite a reasonable student during her school age. She collected her friends who were a lesser academic
performer than her. She would then teach them, and in turn receive admiration from them
She graduated from SMA, and started her college at FKIP at her own decision, and finished her study after five
years.
kelompok enam
5
Occupation history
Shortly after her graduation, she applied to her former SMA and was accepted as an honorary teacher for three years. At
the fourth year, she followed the CPNS examination and was granted the position of a permanent teacher. She
taught with her heart and never complained about her work. But her history was marred by several scandals
involving Mrs.Sorrowati and her student in some kind of love affair.
Marital history
She was married to her husband during her study at college. She admitted that the marriage was not based upon love and
devotion, and it was only an accident. Her husband was only a graduate of SD and never had any permanent job
(rather opposite from her ideal husband figure), and she regarded her as “Mister Know – It – All”. Her husband was
regarded as a suspicious person burnt in jealously. Most of their daily life, they fought each other either orally and
sometimes physically.
Before marrying her husband, Mrs.Sorrowati had numerous, but once at a time, a boyfriend.
Economical status
The family economy was supported by Mrs.Sorrowati. They lived a rather deficient life.
Social relationship and activity
At her adolescene, Mrs.Sorrowati was known to be active in most committee of any event, especially celebrating the
Independence day. She was also known to be fond of singing at many parties, and as a generous girl who lend her
clothing to others in charity show, although she herself was not in an excess condition.
She had many friends, most of the were subjects for her boastings.
She was regarded as a “commoner in religion”
kelompok enam
6
Examiner Mrs.Sorrowati
Good morning
The following Good morning ma’am, how may I help you?
(Glanced the eyes brieftly then face turned
(looking at the eyes, offering to shake hands)
information was down; accepted the hand)
recorded during I’m the psychiatrist here, what is your name
Sorrowati
autoanamnesis and ma’am?
simultaneous How do you feel today?
I feel very bad, doc
voice of Why are you crying? I’m sinful, so much sin had I commit
Yes, and i’m very sure that I may not be
Mrs.Sorrowati was Are you sure it’s that much?
forgiven
generally slow and
...
small But God’s mercy is above all...
I don’t know
I ran away from home, talk to everyone about
May I know what are they? the evil of my husband’s , and I enjoy it so
much
Of course not. Why should I felt guilty if it’s
Is it right to do so?
right.
kelompok
Do you love your husband? enam No way
Why? She hit me at my head
7
Mood
•Anxious
suatu emosi yang meresap dan
•perasaan takut yang
dipertahankan, yang dialami secara disebabkan oleh dugaan
subjektifdan dilaporkan oleh pasien bahaya, yang mungkin
dan terlihat oleh orang lain. berasal dari luar atau
Emotional dalam
suatu kompleks keadaan perasaan •Guilty
dengan komponen psikis, somatic, • perasan bersalah
dan perilaku, yang berhubungan
dengan afek dan mood. •Fatigue
Psychopatologies •keadaan meningkatnya
lmu kedokteran yang mempelajari ketidaknyamanan dan
sebab dan sifat kelainan jiwa. menurunnya efisiensi
Gloomy akibat pekerjaan yang
murung, perasaan sedih berkepanjangan atau
No longer had appetite berlebihan.
hilangnya nafsu makan •Headache pills
Herbalist • pil obat sakit kepala
orang yang ahli dalam herbal kelompok enam
Identifikasi Masalah
9
1. Ny. Sorrowati :
3 bulan yang lalu
Sering bertengkar dengan suaminya, mulai murung dan menangis
Bangun terlambat di pagi hari
Sering terlambat dan sering melamun
Menarik diri dan menolak mengkomunikasikan masalahnya
2 bulan yang lalu
Berat badan dan nafsu makan menurun
Tidak bisa menyelesaikan masalah rumah tangganya
Tidak masuk kerja dan diberi peringatan oleh atasannya
1 bulan yang lalu
Terlihat cemas
Merasa malu dan bersalah untuk setiap pekerjaan yang dilakukan
Lelah dan tidak dapat melakukan apa pun
Mencoba menekan beberapa obat sakit kepala
kelompok enam
10
2. Pemeriksaan psikiatrik
Riwayat penyakit mental dan organobiologic :
Satu tahun yang lalu, perilaku Ny. Sorrowati aneh, sering menceritakan aktivitas pribadinya dan tertawa
di setiap cerita.
Ia sering menyumbang sebagian besar pendapatannya pada acara amal
Ia hampir tidak pernah istirahat tanpa merasa lelah
Kondisi ini berlanjut hingga satu bulan dan berangsur-angsur membaik
Riwayat pekerjaan : setelah menikah Ny. Sorrowati punya skandal cinta dengan muridnya
Riwayat pendidikan: senang dipuji, menyelesaikan kuliah FKIP 5 tahun.
Riwayat pekerjaan: skandal cinta dengan anak murid
Riwayat pernikahan :
Menikah selagi kuliah bukan karena ada cinta dan kesetiaan tapi karena accident.
Suaminya seorang pencemburu. Suaminya tamatan SD dan tidak punya pekerjaan tetap.
Hampir tiap hari mereka perang mulut dan kadang fisik
Status ekonomi : ekonomi di tanggung Ny. Sorrowati dan hidup kekurangan
Hubungan social dan aktivitas
3. Riwayat autoanamnesis : Ny. Sorrowati merasa bersalah
kelompok enam
Analisis Masalah
11
kelompok enam
Hipotesis
12
kelompok enam
13
SINTESIS
kelompok enam
Interpretasi gejala dan tanda
14
kelompok enam
Hubungan Riwayat Hidup Ny. Sorrowati
dengan Kasus
15
a. Riwayat Premorbid
tidak ada faktor pemicu yang dapat menimbulkan gejala.
b. Riwayat Gangguan Mental
riwayat gangguan mental : episode manik terjadi kira-kira selama
satu bulan
c. Riwayat Keluarga
saat kecil bertengkar perhatian orang tua nya ciri awal
dari gangguan kepribadian Histrionik.
d. Riwayat Pendidikan
menyukai apresiasi dari orang lain dan terus menerus mencari
kepuasan menunjukan tanda-tanda gangguan kepribadian
Histrionik
studinya sedikit salah satu stressor
kelompok enam
16
e. Riwayat Pekerjaan
skandal percintaan gangguan kepribadian Histrionik.
f. Riwayat Pernikahan
Married by accident, bukan suami idaman, pertengakaran
dalam rumah tangga stressor kuat
mempunyai banyak pacar pada waktu yang bersamaan
gangguan kepribadian histrionik
g. Status Ekonomi Keluarga,Riwayat Hubungan dan
Aktivitas Sosial
Tidak ada hubungan status sosioekonomi dengan
gangguan depresif
kelompok enam
Interpretasi Informasi
17
Tambahan
Autoanamnesis
Suara Ny. Sorrowati lambat dan kecil, melihat mata sekilas lalu wajah
menunduk
pasien depresi menunjukkan suatu kecepatan dan volume bicara yang menurun,
merespon pertanyaan dengan kata tunggal dan menunjukkan respon yang
melambat terhadap pembicaraan.
Hasil anamnesis awal: Ny. Sorrowati merasa bersalah dan tidak dapat
diampuni.
menunjukkan suatu gejala depresif.
Suami Ny. Sorrowati memukul kepala Ny. Sorrowati dua kali. Pertama
kalinya sebelum Ny. Sorrowati mengalami gejala pada kasus ini sekitar
setahun lalu.
merupakan faktor pemicu gangguan afektif yang terjadi.
Tidak terdapat halusinasi pada Ny. Sorrowati
Gangguan tidak disertai gejala psikotik
Pada anamnesis kedua, Ny. Sorrowati merasa lebih baik, tidak merasa
bersalah lagi dan ingin bercerai dengan suaminya.
???
kelompok enam
18
Pemeriksaan Fisik
Normal
Axis III no diagnose
Konklusi Pemeriksaan Psikiatrik
Main Condition: Kontak fisik dan verbal adekuat, kontak mata minimal,
sikap kooperatif.
Affective state: mood hipotimik, Affect sesuai
Emotional life: labile
Thought process: rasa bersalah, ide untuk bunuh diri, pesimis, hostility
(permusuhan)
Perception and sensation: normal
Intelligence function: normal
Instictual and behavioral drive: tindakan percobaan bunuh diri, hipobulia,
kehilangan nafsu makan, sulit tidur.
Anxiety: tidak ada tanda ansietas
Reality testing ability: gangguan perasaan, berpikir, dan perilaku.
kelompok enam
Diagnosis banding
19
kelompok enam
Penegakan Diagnosis
20
kelompok enam
Kriteria dignosis manik
21
(PPDGJ)
Episode manik
Kesamaan karakteristik dalam afek yang meningkat,
disertai peningkatan dalam jumlah dan kecepatan aktivitas
fisik dan mental, dalam berbagai derajat keparahan.
Kategori ini hanya untuk satu episode manik tunggal (yang
pertama), termasuk gangguan afektif bipolar, episode manik
tunggal. Jika ada episode afektif (depresi, manik atau
hipomanik) sebelumnya atau sesudahnya, termasuk
gangguan afektif bipolar. (F31).
kelompok enam
Cont…
23
kelompok enam
Kriteria Diagnostik Gangguan
24
affektif bipolar (PPDGJ)
Gangguan Afektif Bipolar, Episode Kini
Depresif Berat Tanpa Gejala Psikotik
Untuk menegakkan diagnosis pasti:
Episode yang sekarang harus memenuhi kriteria untuk
episode depresif berat tanpa gejala psikotik (F32.2); dan
Harus ada sekurang-kurangnya satu episode afektif
hipomanik, manik atau campuran di masa lampau
kelompok enam
criteria diagnostic gangguan
25
kepribadian histirionik (PPDGJ)
Gangguan kepribadian dengan cirri-ciri:
ekspresi emosi yang dibuat-buat
bersifat sugestif, mudah dipengaruhi oleh orang lain atau oleh
keadaan
keadaan afektif yang dangkal dan labil
terus menerus mencari kegairahan, penghargaan, dari orang
lain, dan aktifitas dimana pasien menjadi pusat perhatian
penampilan atau pelrilaku yang merangsang yang tidak
memadai
terlalu peduli dengan daya tarik fisik
Untuk diagnosis dibutuhkan paling sedikit 3 dari diatas
kelompok enam
Multiaksial Diagnosis
26
kelompok enam
.Gangguan Afektif Bipolar, Episode Kini
Depresif Berat tanpa Gejala Psikotik
27
Epidemiologi
Laki : perempuan = 1 : 2
Kebanyakan kasus terjadi pada dewasa muda berusia 20-
30 tahun.
Sebagian besar penderita bipolar tidak hanya menderita
bipolar saja tetapi juga menderita gangguan jiwa yang
lain (komorbid). 84 penderita bipolar berusia diatas 65
tahun ternyata:
38,1% terlibat dalam penyalahgunaan alcohol
15,5% distimia
20,5% gangguan cemas menyeluruh
19% gangguan panik.
kelompok enam
28
.Klasifikasi
Berdasarkan Diagnostic and Statistical Manual (DSM)
IV:
Gangguan bipolar I atau tipe klasik ditandai dengan adanya 2
episode yaitu manik dan depresi
Gangguan bipolar II ditandai dengan hipomanik dan depresi
Pada kasus bipolar I
PPDGJ III membaginya dalam klasifikasi yang berbeda
yaitu menurut episode kini yang dialami penderita
kelompok enam
29
Etiologi
PERSPEKTIF BIOLOGIS
Neuroimaging : kelainan dalam regio ventromedial termasuk
cingulata anterior konsisten pada gangguan depresi.
Neurokimiawi : Terdapat peran neurotransmitter serotonin
pada gangguan mood.
Faktor psikoneuroendokrinologi : diduga adanya disregulasi
axis HPA (Hipothalamus-Pituitari-Adrenal)
Faktor psikoneuroimunologi : sitokin menginduksi gejala
mirip depresi
Faktor Genetik : gangguan bipolar mempunyai sifat menurun
yang tinggi dibandingkan depresi unipoar berulang
kelompok enam
Cont…
30
Factor Risiko
Keturunan pertama dari seseorang yang menderita gangguan
bipolar berisiko menderita gangguan serupa sebesar 7 kali.
Risiko pada anak kembar sangat tinggi terutama pada kembar
monozigot (40-80%)
Jenis Kelamin perempuan
Usia: anak-anak hingga 50 tahun, dengan perkiraan rata-rata usia
21 tahun
Obat tekanan darah reserpin, Obat-obatan seperti kokain
Adanya riwayat gangguan dan ketidakseimbangan hormonal dari
aksis hipotalamus-pituitari-adrenal
Kehamilan
kelompok enam
32
kelompok enam
Penatalaksanaan
33
Farmakoterapi
kelompok enam
34
ECT(electroconvulsive therapy)
Non-farmako
Konsultasi
Aktivitas
Edukasi Penderita
kelompok enam
Prognosis
35
kelompok enam
komplikasi
36
bunuh diri
pembunuhan
adiksi
kelompok enam
KDU
37
3A
kelompok enam
DAFTAR PUSTAKA
38
kelompok enam
Pertanyaan dan sanggahan
39
kelompok enam