PSIKONEUROIMUNOLOGI

Oleh : Joni HaryantoOleh : Joni Haryanto, S.Kp., MS, S.Kp., MSDepartemen Keperawatan Departemen Keperawatan DasarDasar

Program Studi Ilmu Keperawatan Program Studi Ilmu Keperawatan Fakultas Ilmu KesehatanFakultas Ilmu Kesehatan

Universitas Indonusa Esa UnggulUniversitas Indonusa Esa Unggul

Psychosocial factors that weaken & strengthen Psychosocial factors that weaken & strengthen the immune systemthe immune system

PendahuluanPendahuluanPengertian PsikoneuroimunologiPengertian PsikoneuroimunologiKepentingan PsikoneuroimunologiKepentingan PsikoneuroimunologiFaktor Psiko-sosial yg memperkuat Faktor Psiko-sosial yg memperkuat

dan melemahkan imunitas tubuhdan melemahkan imunitas tubuhTipe orang yang rentan terhadap Tipe orang yang rentan terhadap

stresor psiko-sosialstresor psiko-sosialSistem imun dapat di modulasi Sistem imun dapat di modulasi

melalui sumber psiko-sosialmelalui sumber psiko-sosial

PsychoneuroimmunologyPsychoneuroimmunology Robert Ader (2000) Robert Ader (2000)

mrpk discipline-hybridmrpk discipline-hybrid Psiko Psiko psikologipsikologi NeuroNeuro neurologineurologi ImunologiImunologi

Merupakan istilah baru Merupakan istilah baru yang digunakan untuk yang digunakan untuk menamakan kajian menamakan kajian interaksi antara behavior, interaksi antara behavior, fungsi neuroendokrin dan fungsi neuroendokrin dan sistem imunsistem imun

What is PNIWhat is PNI ?? Study of theStudy of the interrelationsinterrelations between the between the

endocrine, central nervous systemendocrine, central nervous system and the and the immune system immune system (Cohen & Herbert 1996)(Cohen & Herbert 1996)

More specifically: Drawing on psychology & More specifically: Drawing on psychology & medicine, study of how emotional & mental medicine, study of how emotional & mental states & social conditions (psychosocial factors) states & social conditions (psychosocial factors) reciprocally link, through nervous & endocrine reciprocally link, through nervous & endocrine systems, to immune system & ultimately to systems, to immune system & ultimately to immunological health & diseaseimmunological health & disease

Dasar PNIDasar PNIPercobaan Pavlov ( susu + lonceng + anjing )Percobaan Pavlov ( susu + lonceng + anjing )Kasus kanker payudara lebih sering pada Kasus kanker payudara lebih sering pada

orang melankolis dibandingkan sanguin orang melankolis dibandingkan sanguin (Galen, 200 AD)(Galen, 200 AD)

Proses PikirProses PikirKopingKoping KesehatanKesehatan

PNI dan Sel StresPNI dan Sel Stres Melaui HPA-axis dan ANS Melaui HPA-axis dan ANS

(autonomic nerve system)(autonomic nerve system) Komunikasi CNS dg sistem Komunikasi CNS dg sistem

imun scr bidireksionalimun scr bidireksional Paradigma Paradigma

psikoneuroimunologi psikoneuroimunologi berkonsep stres-sel:berkonsep stres-sel: Ini menjelaskan bahwa pola pikir Ini menjelaskan bahwa pola pikir

dan sistem imun merupakan satu dan sistem imun merupakan satu sama lain yg keterkaitan yg lebih sama lain yg keterkaitan yg lebih dapat diterangkan melalui dapat diterangkan melalui komunikasi sel yg mengalami komunikasi sel yg mengalami stres dan faktor neurotransmiterstres dan faktor neurotransmiter

What has PNI taught us?What has PNI taught us?1.1. Commonplace personal experiences of > Commonplace personal experiences of >

immune-related illness following immune-related illness following stress/emotional trauma, now explicable at stress/emotional trauma, now explicable at biomolecular level. (neural-immune links: Felten biomolecular level. (neural-immune links: Felten et al., 1987; endocrine–immune links: Blalock, et al., 1987; endocrine–immune links: Blalock, 1984)1984)

What has PNI taught us?What has PNI taught us? Helps to explain clinical experiences Helps to explain clinical experiences

like:like: I see a lot of people with so-called problems relating I see a lot of people with so-called problems relating

to dysfunctional immune systems. Things like to dysfunctional immune systems. Things like recurrent coldsores, recurrent infections, even recurrent coldsores, recurrent infections, even hayfever, other allergies. These nearly always occur hayfever, other allergies. These nearly always occur on a background of stress.on a background of stress.

Dr. David Isaacs, Sydney suburban GP, 2000

What has PNI taught us?What has PNI taught us?2.2. Neuroendocrinological system research points Neuroendocrinological system research points

to chronic stress as important contributor in to chronic stress as important contributor in range of immune-related conditions. range of immune-related conditions.

Both children & adults show increased Both children & adults show increased vulnerability to infectious diseases: including vulnerability to infectious diseases: including colds, flus & herpes virus infection, chickenpox, colds, flus & herpes virus infection, chickenpox, mononucleosis, & Epstein-Barr virus (Cohen & mononucleosis, & Epstein-Barr virus (Cohen & Herbert, 1996: Kiecolt-Glaser and & Glaser, Herbert, 1996: Kiecolt-Glaser and & Glaser, 1987)1987)

Variable impact of stress on immune Variable impact of stress on immune systemsystem(Adapted from Robert Sapolsky in Merson, 2001)

What has PNI taught us?What has PNI taught us?

What has PNI taught us?What has PNI taught us?3.3. Certainly no experimental evidence, as Certainly no experimental evidence, as

yet, that mind can cure immune system yet, that mind can cure immune system diseases (Relman & Angell, 2002)diseases (Relman & Angell, 2002)

4.4. Evidence suggests psychosocial variables Evidence suggests psychosocial variables may alter susceptibility, progress & may alter susceptibility, progress & recurrence of these (Taylor, 1999) as recurrence of these (Taylor, 1999) as well as how well pts cope/QOLwell as how well pts cope/QOL

Pendekatan Pendekatan PsikoneuroimunologiPsikoneuroimunologi Pasien tersebut akan tidak Pasien tersebut akan tidak

lekas sembuh, bahkan akan lekas sembuh, bahkan akan terjadi penyakit lain.terjadi penyakit lain.

Kebingungan akan menstmulasi Kebingungan akan menstmulasi hipotalamus menskresi CRFhipotalamus menskresi CRF

CRF akan menginduksi pituitari CRF akan menginduksi pituitari menghasilkan ACTH dan menghasilkan ACTH dan meningkatmeningkat

Kelenjar adrenal akibat ACTH Kelenjar adrenal akibat ACTH menghasilkan cortisol dalam menghasilkan cortisol dalam jumlah banyakjumlah banyak

Ini mampu mensupresi limfosit Ini mampu mensupresi limfosit TT

Akibatnya ketahanan tubuh Akibatnya ketahanan tubuh menurunmenurun

Kepentingan Kepentingan PsikoneuroimunologiPsikoneuroimunologi Perawat potensi sbg stressorPerawat potensi sbg stressor Dimana klien kehilangan fungsi fisiologisDimana klien kehilangan fungsi fisiologis Emosi klien / pasien sangat labilEmosi klien / pasien sangat labil Interaksi perawat dg klien akan memicu Interaksi perawat dg klien akan memicu

proses adaptasi dari kemampuan koping proses adaptasi dari kemampuan koping yg telah di kelola oleh perawat.yg telah di kelola oleh perawat.

Proses adaptasi akan memicu perbaikan Proses adaptasi akan memicu perbaikan sistem ketahanan tubuhsistem ketahanan tubuh

PerawatPerawat mother instinkmother instink

NurturenNurturen GenerativeGenerative

ProtectiveProtective

to care to care (perilaku terapiutik) (perilaku terapiutik)

Client / PatientClient / Patient semakin sehat semakin sehat

Kepentingan Kepentingan PsikoneuroimunologiPsikoneuroimunologi

Proses Keperawatan dan Proses Keperawatan dan PsikoneuroimunolgiPsikoneuroimunolgi

Pengkajian dg dasar caring Pengkajian dg dasar caring akan menimbulkan kesan akan menimbulkan kesan diterimanya pasien/klienditerimanya pasien/klien

Diagnose keperawatan akan Diagnose keperawatan akan menjembatani aplikasi menjembatani aplikasi profesionalprofesional

Intervensi lebih memantapkan Intervensi lebih memantapkan dalam pelaksanaan tindakan dalam pelaksanaan tindakan kpd klien/pasienkpd klien/pasien

Tindakan keperawatan scr Tindakan keperawatan scr langsung memberikan langsung memberikan sentuhan dan upaya sentuhan dan upaya meminimalkan stressor yg meminimalkan stressor yg negatifnegatif

Evaluasi untuk mengetahui Evaluasi untuk mengetahui proses HPA-axis terjadi dan proses HPA-axis terjadi dan timbul kesembuhan timbul kesembuhan

Faktor Psikososial Yang Faktor Psikososial Yang Memperkuat Dan Melemahkan Memperkuat Dan Melemahkan

Imunitas TubuhImunitas TubuhProblems Problems that can beset that can beset immune systemimmune system AgeAge Genetic disordersGenetic disorders Infectious diseasesInfectious diseases NutritionNutrition ChemotherapyChemotherapy IrradiationIrradiation AllergiesAllergies SStresstress = focus of PNI = focus of PNI

Psychosocial factors modulating Psychosocial factors modulating immunityimmunity

a. Weakening influencesa. Weakening influences Changes in immune system found to Changes in immune system found to

accompany stressful or conflictual social accompany stressful or conflictual social relationships. These include:relationships. These include:

- Loss of an intimate relationship from Loss of an intimate relationship from death or divorce (Bartrop et al., 1977)death or divorce (Bartrop et al., 1977)

Worse effects if depressed before and Worse effects if depressed before and after the loss (Irwin et al., 1987)after the loss (Irwin et al., 1987)

Psychosocial Factors Modulating Psychosocial Factors Modulating ImmunityImmunity

- Loneliness. Lonely people have poorer Loneliness. Lonely people have poorer health. Amongst exam students they had health. Amongst exam students they had more extreme immuno-compromise more extreme immuno-compromise (Kiecolt-Glaser et al., 1984)(Kiecolt-Glaser et al., 1984)

- Poorer marital quality for married couples - Poorer marital quality for married couples - associated with latent virus antibody associated with latent virus antibody response (Kennedy et al., 1988)response (Kennedy et al., 1988)

- Caring for a terminally-ill patient (Esterling Caring for a terminally-ill patient (Esterling et al., 1996)et al., 1996)

Psychosocial Factors Modulating Psychosocial Factors Modulating ImmunityImmunity

• Job stress (Dorian, et al., 1985) &Job stress (Dorian, et al., 1985) & unemployment (Arnetz et al., 1987). Both linked unemployment (Arnetz et al., 1987). Both linked

to lowered lymphocyte reactivity to mitogento lowered lymphocyte reactivity to mitogen• Tendency to ruminate during stressful events Tendency to ruminate during stressful events

such as exam periods (Workman & La Via, 1987)such as exam periods (Workman & La Via, 1987)

Psychosocial Factors Modulating Psychosocial Factors Modulating ImmunityImmunity

Academic stress can lead to immunological Academic stress can lead to immunological changes and illness. Glaser et al. (1985) assessed changes and illness. Glaser et al. (1985) assessed 40 240 2ndnd year medical students 6 wks before and year medical students 6 wks before and during final exams. Lymphocytes, NK cells and NK during final exams. Lymphocytes, NK cells and NK cytotoxic activity and interferon levels were lowercytotoxic activity and interferon levels were lower

Psychosocial Factors Psychosocial Factors Modulating ImmunityModulating Immunity

Starting kindergarten can raise cortisol Starting kindergarten can raise cortisol levels and negatively alter immune levels and negatively alter immune measures (Boyce et al.,1995)measures (Boyce et al.,1995)

Clinical depression is associated with Clinical depression is associated with several alterations in immunity e.g. fewer several alterations in immunity e.g. fewer lymphocytes in response to mitogens lymphocytes in response to mitogens (chemical challenges), lowered NK cell (chemical challenges), lowered NK cell activity and changes in WBC numbers activity and changes in WBC numbers (Herbert & Cohen, 1993)(Herbert & Cohen, 1993)

Pendekatan Pendekatan PsikoneuroimunologiPsikoneuroimunologi

Sikap perawat akan Sikap perawat akan mempengaruhi mempengaruhi persepsi klienpersepsi klien

Perilaku perawat yang Perilaku perawat yang otoriter dan otoriter dan cenderung sadisme cenderung sadisme merupakan tindakan merupakan tindakan yang dapat yang dapat menimbulkan penyakit menimbulkan penyakit baru / tidak terjadi baru / tidak terjadi kesembuhankesembuhan

Perlu ada perubahan Perlu ada perubahan sikap perawat menjadi sikap perawat menjadi ::Sikap CaringSikap CaringAltruistikAltruistikProfesionalProfesional

Psychosocial Factors Psychosocial Factors Modulating ImmunityModulating Immunity

Changes in the immune system have also Changes in the immune system have also been found to accompany stressful or been found to accompany stressful or conflictual social relationships. These conflictual social relationships. These include:include:

- Loss of an intimate relationship from death Loss of an intimate relationship from death or divorce (Bartrop et al., 1977)or divorce (Bartrop et al., 1977)

Worse effects if depressed before & Worse effects if depressed before & after the loss (Irwin et al., 1987) after the loss (Irwin et al., 1987)

Psychosocial Factors Psychosocial Factors Modulating ImmunityModulating Immunity

Perceived severe ‘daily hassles’ predict lower NK cell activity (Levy et al., 1989)

Across studies it appears that more severe & long-term were stressors, more vulnerable individuals were to health-related problems