Dr.

RONI SUBAGYO, Sp KJ
 SCHIZOPHRENIA QUIZ
True False Statement
Schizophrenia is caused by poor parenting
Using drugs causes schizophrenia
A person with schizophrenia has a split personality
Children can be diagnosed with schizophrenia
About half of people with schizophrenia also have problems with subst
ance abuse/dependence
It is very expensive to treat schizophrenia
People with schizophrenia can recover from their illness
Most people with schizophrenia are violent criminals
Schizophrenia affects people of all races, cultures and social classes

People with schizophrenia should not have children

People with schizophrenia are capable of making their own decisions a
bout treatment and other areas of their lives
 SCHIZOPHRENIA

 A serious mental disorder

 The top ten causes of disability
 Affects 1 in 100 people worldwide
 Approximately 24 million people worldwide
 Medical illness
 Experience a greater number of other conditions
 Stress makes symptoms worse
 NOT caused by childhood trauma, bad parenting, or poverty
 Proper diagnosis and treatment are available
 Not everyone who is diagnosed with schizophrenia has the same sym
ptoms
 Warning Signs and Symptoms

 Sleep disturbance
 Appetite disturbance
 Marked unusual behaviour
 Speech that is difficult to follow
 Marked preoccupation with unusual ideas
 Ideas of reference-things have special meanings
 Persistent feelings of unreality
 Changes in the way things appear, sound or smell
 “Positive” Symptoms

 Hallucinations
 Delusions
 Thought disorder
 Altered sense of self
 “Negative” Symptoms

 Lack of motivation or apathy

 Blunted feelings or affect
 Depression
 Social withdrawal
 Poverty of speech and thought
 Catatonic behaviour
 “Cognitive” Symptoms

 Problem of attention
 Remembering things
 Concentrating
 Memory impairment
What Causes Schizophrenia ?

1. Viruses
2. Injuries in early life
3. Lack of oxygen at birth
4. Genetic factors
 DSM-IV Diagnostic Criteria for
Schizophrenia

A. Characteristic symptoms : Two or more of the following, each present for

a significant portion of time during a one-month period :
- delusions
- hallucinations
- disorganised speech (eg, frequent derailment or incoherance)
- grossly disorganised or catatonic behaviour
- negative symptoms (ie, affective flattening, alogia, or avolition)
Note : Only one Criterion A symptom is required if delusions are bizarre or
hallucinations consist of a voice keeping up a running commentary on t
he person’s behaviour or thoughts, or two or more voices conversing
with each other.
 DSM-IV Diagnostic Criteria for
Schizophrenia

B. Social/occupational dysfunction :

since the onset of the disturbance, one or more major areas of functioni
ng, such as work, interpersonal relations, or self-care, are markedly belo
w the level previously achieved

C. Duration : Continous signs of the disturbance persist for at least six mon
ths. This six-month period must include at least one month of symptoms
(or less if successfully treated) that meet Critetion A.

D. Exclusion : of schizoaffective disorder and mood disorder with psychotic

features
 DSM-IV Diagnostic Criteria for
Schizophrenia

E. Substance/general medical condition exclusion :

the disturbance is not due to the direct physiological effects of a

substance (eg, a drugs of abuse, a medication) or a general

F. Relationship to a pervasive developmental disorder : if there is a

history of autistic disorder or another pervasive development dis
order, the diagnosis of schizophrenia is made only if prominent d
elusions or hallucinations are also present for at least a mont (or
less if successfully treated).
 Early Intervention

“Treatment for schizophrenia is most effective if it

is begun early – as soon as possible after symptoms
Appear. In most countries, ongoing assessments and
Tests will be used to monitor the person’s health and
Wellness – just as in treating any other chronic
medical condition”
 Medication

“There is considerable variation in the therapeutic

And side effects of antipsychotic medication.
Doctors and patients must carefully evaluate the
Trade-off between efficacy and side effect in
choosing an appropriate medication. What works
For one person may not work for another.”
 Medication treatment
 Individual supportive therapy
 Cognitive and psychosocial therapies
 Family psychoeducation and support
 Social support
 Case management
 Housing
 Financial support
 Vocational support
“Family and friends should also be
familiar with signs of “relapse”.
These vary betweenIndividuals, but
often a person may withdraw from
Activities and other people, and you
may notice that they are taking less
care of themselves.”
 GANGGUAN ANXIETAS
PENDAHULUAN

 Dari seluruh gangguan jiwa, mungkin gangguan anxietas

merupakan gangguan yang terbanyak.
 Wanita (30,5% lifetime prevalence) > pria (19,2% lifetime p
revalence)
 Kira-kira 2 – 4% penduduk pernah mengalami gangguan a
nxietas
 Umumnya mengunjung dokter non psikater dengan keluha
n somatic > stigma gangguan jiwa
 Anggapan gangguan jiwa = psikosis = inferioritas
Anxietas Normal dan Patalogis
Anxietas Normal :
 Compensated, tidak terganggu
 Diperlukan sebagai dorongan
 berprestasi dan melindungi diri
Anxietas Patalogis :
 - Decompensated > sakit
 Prestasi dan performance
 terganggu
Gejala Umum Gangguan Anxietas :

Merupakan suatu sindroma :

 Rasa cemas
 Hiperaktivitas vegetatif
 Ketegangan khawatir berlebihan – tentang hal-hal
yang akan datang (apprehensiveexpectation)
 Kewaspadaan bertambah
Perlu Diperhatikan :
 Pada gangguan anxietas banyak keluhan s
omatic
 Tidak semua punya stressor penyebab
 Sering komorbid, terutama dengan ganggu
an mood (depresi)
 FAKTOR PENYEBAB

 STRES KEHIDUPAN
KONFLIK INTERPERSONAL
KONFLIK KELUARGA
PERISTIWA KEHILANGAN/KEKECEWAAN
 NAPZA/NARKOBA
 PENYAKIT MEDIS
 OBAT
 PENGALAMAN BURUK MASA LALU
 KEPRIBADIAN
 GENETIK
 GANGGUAN CEMAS MENYELURUH

 KEKHAWATIRAN & KECEMASAN SUBYEKTIF >>

 WASPADA & SIAGA
 TERJADI HAMPIR SETIAP HARI/MENETAP
 TIDAK TERBATAS PD SITUASI TERTENTU
 KETEGANGAN MOTORIK
 HIPERAKTIVITAS OTONOMIK
 GANGGUAN PANIK
 GX PSIKIS
KECEMASAN HEBAT
TAKUT MATI/KEHILANGAN KONTROL
DEPERSONALISASI
DEREALISASI
 GX FISIK
PALPITASI/BERDEBAR, TAKIKARDIA, NYERI DADA
RASA TERCEKIK, SESAK NAPAS
BERKERINGAT, GEMETAR, PUSING, KEPALA
RINGAN, MAU PINGSAN, RASA DINGIN, MUAL
FOBIA SOSIAL

 MENGHINDARI SITUASI SOSIAL TERTENTU DI LUAR KELUA

RGA
 berbicara/tampil di depan umum
 makan minum/menulis di depan umum
 menggunakan toilet umum
 berkencan, pergi ke pesta/aktivitas sosial lain
 berbicara pada atasan
 bertemu orang asing
 TAKUT MENJADI PUSAT PERHATIAN/DIKRITIK
GANGGUAN OBSESI KOMPULSI

 ISI PIKIRAN YG KUKUH/PERSISTEN TTG

SATU HAL
 TIMBUL PERASAAN TAKUT/CEMAS
 GOK DIRASAKAN PERASAAN ASING, TD
K DISUKAI/DITERIMA, TDK DPT DITEKAN
 SADAR AKAN GGN & ADA KEBUTUHAN
UTK MELAWAN
GEJALA CEMAS PD ANAK & REMAJA
 TEMPER TANTRUM
 ENURESIS
 MENOLAK SEKOLAH/MEMBOLOS
 PRESTASI BELAJAR TURUN
 TERISOLASI DARI TEMAN
 PERILAKU MENGAMBIL RESIKO
 PENGGUNAAN NARKOBA
 MIMPI BURUK
 KELUHAN FISIK TDK KHAS
BAGAIMANA MENDIAGNOSIS ?

 50-95% PX PSIKIATRI DATANG DG KELUHAN SOMATIK

 BIASANYA LBH DARI SATU, TDK JELAS & SULIT DITERAN
GKAN SESUAI PENYAKIT ORGANIK

 KELELAHAN
 PUSING/SAKIT KEPALA
 NYERI DADA, SENDI
 MASALAH GASTROINTESTINAL
  BB
 PENATALAKSANAAN

 TUJUAN TERAPI
ME GX KECEMASAN (FISIK, PSIKOLOGIS)
MEMBERIKAN KETERAMPILAN  MENGATASI GX
MEMPERBAIKI POLA PIKIR
TERAPI DIBERIKAN SAMPAI GX DPT DIKENDALIKAN
 BERFUNGSI NORMAL
DEPRESI
Depresi pada praktek umum
 Pasien yang ditemui di praktek umum sering dat
ang dengan keluhan fisik (somatik) bukan keluha
n psikologis
 Keluhan somatik yang sering diutarakan oleh pas
ien
- Sakit kepala
- Gangguan saluran nafas
- Gangguan saluran pencernaan
- Nyeri pada berbagai bagian tubuh
 DEPRESI
ANXIETAS
 Perasaan sedih GEJALA TUMP  Gemetar
 Kurang minat ANG TINDIH
 Kekakuan
 Retardasi  Gangguan Tidur
otot
psikomotor  Kelelahan
Gangguan  Sesak nafas
  Agitasi psikomotor
nafsu makan  Khawatir/rasa ber  Berkeringat
 Merasa tidak salah  Mulut kering
berdaya Sulit berkonsentrasi  Mual
 Putus asa Ide bunuh diri

90 % pasien depresi mempunyai gejala Anxietas

 Angka Prevalensi Depresi pada
Gangguan Medis Kronis
Stroke 47.00%
45.00%
Kanker rawat inap 42.00%
39.00%
Lansia rawat inap 36.00%
33.00%
Rawat Inap 33.00%
9.40%
Populasi umum 5.80%

0.00% 10.00% 20.00% 30.00% 40.00% 50.00%

 Depression as a whole body disorder

 Endocrine changes.
 Immune changes.
 Cardiovascular changes.
 Cancer.
 Endocrine changes in depression-1.

 Disturbances of the HPA axis lead to:-

 Hypercortisolaemia and dexamethasone non-su
ppression (DST test).
 Impaired DST test predicts recurrence and chro
nicity of depression.
 Impaired TRH test common in depression.
 Levels of sex hormones (loss of libido) and grow
th hormone (tissue repair decreased) lower in ch
ronic depression.
 Endocrine changes in depression-2.
 Consequences of hypercortisolaemia on general
metabolism:-
 Disturbance in glucose metabolism leading to in
sulin resistance and diabetes.
 Increased protein metabolism leading to loss of
muscle mass and bone calcium;fractures more li
kely.
 Change in lipid metabolism and fat distribution;a
therosclerosis more likely.
 Inhibition of neurotrophic factor synthesis leadin
g to reduced synaptogenesis and neuronal repai
r: neurodegeneration more likely.
 Immune changes in depression-1.
 Depression as an inflammatory disorder:-
 Over 40 different immune markers ( most of the
m inflammatory markers!) related to depression
( Zorrilla et al,2000)
 Increased peripheral and central pro-inflammato
ry cytokines associated with depression ( IL-1,-6,
TNF,IFN). Rise in acute phase proteins.
 Epidemiological studies show increase in rheum
atoid arthritis and autoimmune disease in patient
s with depression.
 Immune changes in depression-2.
 Incidence of dementia increased in patients with
chronic depression.This is linked to the neurode
generative effects of cortisol,the pro-inflammator
y cytokines and inflammatory changes associate
d with the rise in prostaglandin E2 and nitric oxid
e in brain.
 Pro-inflammatory cytokines also stimulate HPA
axis and contribute to hypercortisolaemia.
 Symptoms of depression ( anorexia,sleep distur
bance,anhedonia,cognitive changes etc) a form
of sickness behaviour ( Dantzer et al.)
Depression and cardiovascular functio
n-1.
 Increased peripheral sympathetic activity and su
sceptibility to environmental stressors contribute
to hypertension.
 Accumulation of visceral fat and increased fat de
posits in coronary arteries associated with hyper
cortisolaemia and insulin resistance.
 Increased blood clotting and elevation of circulati
ng homocysteine contribute to cardiovascular ch
anges.
 Cancer and depression-1.

 Some epidemiological evidence that high incide

nce of depression preceeds cancer (Shekellel et
al.1981;Linkins & Comstock, 1990).
 However,progression of cancer linked to psychol
ogical factors (20/26 studies) rather than initiatio
n of cancer (6/12 studies).
 Psychotherapy can enhance period of survival a
fter metastatic breast cancer (Spiegel et al.1989).
 Cancer and depression-2.

 Possible mechanisms:-
 Natural killer cell suppression linked to onco
genic virus induced cancers and lymphoreti
cular cancers (Souberbielle & Dalgleish,199
4).
 IFN,TNF,IL-8 &TGF all raised in depression
and involved in angiogenesis necessary for
tumour growth.
 Depression
 Affective: afek depresi (anak: iritabel), anhed
onia sedikitnya 2 minggu.
 Cognitive: merasa tidak berguna/merasa ber
salah, tidak berpengharapan, peragu, bunuh
diri.
 Somatic (vegetative): perubahan BB/napsu
makan, tidur (insomnia atau hipersomnia), k
ehilangan energi/fatigue, agitasi/retardasi ps
ikomotor.
 GANGGUAN DEPRESI
A. Kriteria mayor
  Trias depresi:
1. mood depresi
2. hilang minat dan kesenangan
3. hilang energi dan mudah lelah
B. Kriteria minor
1. sulit konsentrasi
2. hargadiri/ kepercayaan kurang
3. rasa bersalah berlebihan
4. pandangan tentang masa depan yang suram
5. pikiran tentang kematian/ ide-ide bunuh diri
6. perubahan pola tidur
7. perubahan napsu makan
Depresi ringan
 2A+2B
 Tidak ada gejala yang sangat berat
 Hanya ada sedikit kesulitan dalam pek
erjaan dan kegiatan sosial
 Gejala harus bertahan minimal 2 mingg
u
Depresi sedang
 2 A + 3/4 B
 Terdapat hendaya yang nyata dalam pe
kerjaan dan kegiatan sosial
 Gejala harus bertahan minimal 2 mingg
u
Depresi berat
 3A+4B
 Tiak mampu melakukan pekerjaan atau
kegiantan sosial
 Gejala harus bertahan minimal 2 minggu
Macam Gangguan Depresi ?

 Dua penyebab keadaan depresi yang um

umnya tidak dipertimbangkan sebagai ga
ngguan afektif adalah:
 Berkabung

 Postpartum blues
Pengobatan Terbaik

 Medikasi + terapi psikososial

 Terapi psikososial terutama membantu m
engurangi angka kekambuhan