SKISOFRENIA

Dr Dickson Legoh, SpKJ

 What is Psychosis?
• Generic term
• “Break with Reality”
• Symptom, not an illness
• Caused by a variety of conditions that affect
the functioning of the brain.
• Includes hallucinations, delusions and thought
disorder
 SKISOFRENIA
GGN BERAT DLM BIDANG : PIKIRAN, PERASAAN,
PERBUATAN, PERSEPSI, KEINGINAN, DORONGAN
KEHENDAK & PENGENDALIAN

ONSET SULIT DITENTUKAN,BIASANYA DI DAHULUI FASE

PRODROMAL (GEJALA RINGAN & TDK KONSISTEN)

GEJALA PSIKOLOGIK MAJEMUK : DISTORSI PIKIRAN &

PERSEPSI → WAHAM & HALUSINASI YG KHAS, AFEK TDK
WAJAR / TUMPUL, SIKAP/PERILAKU ANEH, PERASAAN &
PIKIRAN DIKETAHUI ORANG ATAU DIKENDALIKAN
KEKUATAN GAIB DARI LUAR

PERJALANAN PENY SULIT DITENTUKAN, KRONIS,

DETERIORASI TERGANTUNG : GENETIK, FISIK & SOSIAL
BUDAYA.
• Schizophrenia occurs with regular frequency
nearly everywhere in the world in 1 % of
population and begins mainly in young age
(mostly around 16 to 25 years).
 sejarah

• 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)
 Course of Illness

• Course of schizophrenia:
– continuous without temporary improvement
– episodic with progressive or stable deficit
– episodic with complete or incomplete remission

• Typical stages of schizophrenia:

– prodromal phase
– active phase
– residual phase
 PEDOMAN DIAGNOSTIK UMUM

I. PALING KURANG 1 GEJALA

1. a. THOUGHT ECHO
b. THOUGHT INSERTION OR WITHDRAWAL
c. THOUGHT BROADCASTING

2. a. DELUSION OF CONTROL (WAHAM DIKENDALIKAN)

b. DELUSION OF INFLUENCE (WAHAM PENGARUH)
c. DELUSION OF PASSIVITY
d. DELUSION OF PERCEPTION
3. HALUSINASI PENDENGARAN
a. SUARA BERKOMENTAR TENTANG
PERILAKUNYA
b. SUARA-SUARA SALING BERBICARA /
BERDISKUSI TENTANG HAL IHWALNYA
c. SUARA LAIN DARI SALAH SATU BAGIAN
TUBUHNYA

4. WAHAM MENETAP LAIN YG MENURUT BUDAYA SETEMPAT

DIANGGAP TDK WAJAR / MUSTAHIL
II. PALING KURANG 2 GEJALA

5. HALUSINASI MENETAP DARI PANCA INDERA APA

SAJA, BISA DISERTAI WAHAM TANPA KANDUNGAN
AFEKTIF YG JELAS, ATAU IDE BERLEBIHAN YG MENETAP
ATAU BILA TERJADI SETIAP HARI SELAMA
BERMINGGU2 / BERBLN TERUS-MENERUS.

6. ARUS PIKIRAN TERPUTUS ATAU MENGALAMI

SISIPAN → INKOHERENSI, IRRELEVANSI ATAU
NEOLOGISME.

7. PERILAKU KATATONIK : GADUH GELISAH,

POSTURING, FLEKSIBILITAS CEREA,
NEGATIVISME, MUTISME, STUPOR.
8. GEJALA NEGATIF : APATIS, BICARA JARANG,
RESPONS EMOSIONAL YG TUMPUL / TDK WAJAR,
PENARIKAN DIRI DARI PERGAULAN SOSIAL,
MENURUNNYA KINERJA SOSIAL (BUKAN OLEH
DEPRESI ATAU REAKSI NEUROLEPTIKA)

9. SUDAH BERLANGSUNG 1 BULAN (DI LUAR FASE

PRODROMAL)

10. PERUBAHAN KONSISTEN BERMAKNA ASPEK

PERILAKU → HILANGNYA MINAT, HIDUP TAK
BERTUJUAN, TDK BERBUAT SESUATU, LARUT DLM
DIRI SENDIRI & PENARIKAN DIRI SECARA SOSIAL.
 Positive and Negative Symptoms

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. SKISOFRENIA 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. SKISOFRENIA 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. SKISOFRENIA 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. SKISOFRENIA 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
 GANGGUAN SKISO 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 SKISO AFEKTIF TIPE MANIK

PEDOMAN DIAGNOSTIK :

1. PED DIAGNOSTIK UMUM

2. ADA EPISODE SKIZOAFEKTIF MANIK YG TUNGGAL MAUPUN

BERULANG DGN SEBAGIAN BESAR TIPE MANIK.

3. AFEK HRS MENINGKAT SECARA MENONJOL ATAU TAK

BEGITU MENONJOL TETAPI DISERTAI IRITABILITAS ATAU
KEGELISAHAN YG MEMUNCAK.

4. DLM EPISODE YG SAMA HRS JELAS ADA SATU ATAU LEBIH

BAIK LAGI KALAU DUA GEJALA SKIZOFRENIA YG KHAS.
 II. GGN SKIZOAFEKTIF TIPE DEPRESIF

PEDOMAN DIAGNOSTIK

1. PED DIAGNOSTIK UMUM

2. ADA EPISODE SKIZOAFEKTIF TIPE DEPRESIF YG TUNGGAL
MAUPUN BERULANG DGN SEBAGIAN BESAR TIPE DEPRESIF
3. AFEK DEPRESIF HRS MENONJOL DISERTAI OLEH SEDIKITNYA
DUA GEJALA KHAS, BAIK DEPRESIF MAUPUN KELAINAN
PERILAKU TERKAIT SEPERTI TERCANTUM DLM URAIAN UTK
KRITERIA EPISODE DEPRESIF
4. DLM EPISODE YG SAMA HRS JELAS ADA SEDIKITNYA SATU
ATAU LEBIH LAGI KALAU DUA GEJALA KHAS SKIZOFRENIA
 III. GGN SKIZOAFEKTIF TIPE CAMPURAN

• GGN DGN GEJALA2 SKIZOFRENIA BERADA

SECARA BERSAMA-SAMA DGN GEJALA-
GEJALA AFEKTIF BIPOLAR CAMPURAN
 Prognosis
• Some of the predictors of outcome are the
consequence of a less severe illness

• Predicting risk of suicide

» Acute exacerbation of psychosis
» Depressive symptoms
» History of attempted suicide
 Genetics of Schizophrenia

• Many psychiatric disorders are multifactorial (caused

by the interaction of external and genetic factors)
and from the genetic point of view very often
polygenically determined.

• Relative risk for schizophrenia is around:

– 1% for normal population
– 5.6% for parents
– 10.1% for siblings
– 12.8% for children
 Etiology of Schizophrenia

• The etiology and pathogenesis of

schizophrenia is not known

• It is accepted, that schizophrenia is „the group

of schizophrenias“ which origin is
multifactorial:
– internal factors – genetic, inborn, biochemical
– external factors – trauma, infection of CNS, stress
 Etiology of Schizophrenia - Dopamine
Hypothesis
• The most influential and plausible are the hypotheses, based on
the supposed disorder of neurotransmission in the brain, derived
mainly from
1. the effects of antipsychotic drugs that have in common the ability to
inhibit the dopaminergic system by blocking action of dopamine in the
brain
2. dopamine-releasing drugs (amphetamine, mescaline, diethyl amide of
lysergic acid - LSD) that can induce state closely resembling paranoid
schizophrenia

• Classical dopamine hypothesis of schizophrenia: Psychotic

symptoms are related to dopaminergic hyperactivity in the brain.
Hyperactivity of dopaminergic systems during schizophrenia is
result of increased sensitivity and density of dopamine D2
receptors in the different parts of the brain.
 Etiology of Schizophrenia -
Contemporary Models
• Dopamine hypothesis revisited: various neurotransmitter
systems probably takes place in the etiology of schizophrenia
(norepinephric, serotonergic, glutamatergic, some peptidergic
systems); based on effects of atypical antipsychotics
especially.

• Contemporary models of schizophrenia conceptualize it as a

neurocognitive disorder, with the various signs and symptoms
reflecting the downstream effects of a more fundamental
cognitive deficit:
– the symptoms of schizophrenia arise from “cognitive dysmetria”
(Nancy C. Andreasen)
– concept of schizophrenia as a neurodevelopmental disorder (Daniel R.
Weinberger)
 Etiology of Schizophrenia -
Neurodevelopmental Model
• Neurodevelopmental model supposes in schizophrenia the
presence of “silent lesion” in the brain, mostly in the parts,
important for the development of integration (frontal, parietal
and temporal), which is caused by different factors (genetic,
inborn, infection, trauma...) during very early development of
the brain in prenatal or early postnatal period of life.
• It does not interfere too much with the basic brain functioning
in early years, but expresses itself in the time, when the
subject is stressed by demands of growing needs for
integration, during formative years in adolescence and young
adulthood.
 More modern approaches emphasize other transmitter systems, too

“1-Dopamine adjusts
the volume—Blocked
by antipsychotics

2-Acetycholine and
GABA filter signal
from noise

3-Glutamate imprints
new memories”

30
Robert Freedman
 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.

chlorpromazine, chlorprotixene, clopenthixole,

conventional levopromazine, periciazine, thioridazine
antipsychotics droperidole, flupentixol, fluphenazine, fluspirilene,
(classical haloperidol, melperone, oxyprothepine, penfluridol,
neuroleptics) perphenazine, pimozide, prochlorperazine,
trifluoperazine
atypical amisulpiride, clozapine, olanzapine, quetiapine,
antipsychotics risperidone, sertindole, sulpiride
 Psychosocial Factors

• Expressed emotion
• Stressful life events
• Low socioeconomic class
• Limited social network
 Anti Psikotik Tipikal

• Low potency: • High potency:

– Chlorpromazine – Haloperidol
– Thioridazine – Fluphenazine
– Mesoridazine – Thiothixene
– Loxapine (mid)
 Efek samping Anti psikotik tipikal

• Acute dystonia
• Parkinsonian side effects (EPS)
• Akathisia
• Tardive dyskinesia
• Sedation, orthostasis, QTC prolongation,
anticholinergic, lower seizure threshold,
increased prolactin
 Anti psikotik Atipikal
• Risperidone
• Olanzapine
• Quetiapine
• Clozapine
• Ziprasidone
• Aripiprazole (new-partial DA agonist)
 Efek samping anti psikotik atipikal

• Sedation
• Hyperglycemia, new-onset diabetes
• Anticholinergic effects
• Less prolactin elevation
• QTC prolongation
• Some EPS
• Increased lipids
• Psikoterapi
»Education of patient and carers
»Reduction of high expressed emotion –
shown to affect relapse rates
»Cognitive behavioural therapy –
controversial
»Rehabilitation
»Self –help – Schizophrenia Ireland
 Prognosis
• 22% have one episode and no residual
impairment
• 35% have recurrent episodes and no residual
impairment
• 8% have recurrent epsiodes and develop
significant non-progressive impairment
• 35% have recurrent episodes and develop
significant progressive impairment
• The majority therefore do not recover fully
• Suicide rate is up to 13%
• Little evidence that anitpsychotic have altered
the course of illness for most patients
• However, evidence that prolonged psychosis
which is untreated has a bad prognosis
• 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
• Some of the predictors of outcome are the
consequence of a less severe illness

• Predicting risk of suicide

» Acute exacerbation of psychosis
» Depressive symptoms
» History of attempted suicide
“He saw the world in a way no one could have imagined.”

43
44
•Terimakasih