Download - CRS Gangguan Skizoafektif Tipe Manik Ny.E

7/25/2019 CRS Gangguan Skizoafektif Tipe Manik Ny.E

1/57

Keterangan umum

Nama : Ny E

Umur : 42 thn

Pekerjaan : ibu rumah tangga

Alamat : Kiara condong

Agama : Islam

Suku : Sunda

gl !asuk "S#S : $2 %ebruari 2&&'

gl (emeriksaan : $) %ebruari 2&&'


2/57

#eteroanamnesa

alasan di o(name: gelisah* marah+marah* menggigitayah,

"I-A.A PEN.AKI SEKA"AN/

sejak 0anuari 2&&1 setelah (ulang dari "S "iau os tidak(ernah kontrol lagi tidak ada yang mengantar* kadang+kadang os tidak mau kontrol3 dan tidak teratur minumobat, hari setelah sam(ai di rumah* os kembali gelisah*

mondar+mandir* sulit tidur* banyak makan, 5s menjadibanyak bicara bila diajak bicara menyambung* mengenalorang disekitarnya* sering gonta+ganti (akaianalasannya (akaian basah atau kotor,


3/57

6 5s tidak betah tinggal di rumah* ingin

keluar rumah terus, 7ebera(a bulan

S!"S os kabur dari rumah selama 2 hari*

ditemukan oleh keluarga di alun+alun,


4/57

"I-A.A PEN.AKI 8A#U9U

6 5s menderita gangguan jia sejak S8*

berobat alternati;, Pertama kali di raat

(ada tahun 2&& di "S#S karena gelisah*

marah+marah* di raat 2 minggu, Pasien

(ulang dengan (erbaikan* minum obat

tidak teratur dan tidak kontrol, Nama obat

tidak diketahui, -arna orange


5/57

6 7ulan se(tember tahun 2&&1*(asienkembali di raat di Salamun karenagelisah* marah+marah* diraat selama 2

minggu, Pasien (ulang dengan (erbaikan*minum obat dan kontrol tidak teratur,5bat se(erti (ertama kali diraat,

6 Pada bulan 8esember tahun 2&&1 (asienkembali di raat di Salamun selama $'hari, Pulang dengan (erbaikan,


6/57

6 Pada tanggal > 0anuari 2&&'* (asien

kembali di raat di "S0 "iau selama $&

hari, Pulang dengan (erbaikan,

6 "I-A.A PEN.AKI SE"UPA 8A9A!

KE9UA"/A

6 Kakak sulung menderita gangguan jia


7/57

SI%A+SI%A 8A9A! KE9UA"/A

6 A.A#') tahun3 : si;at (emarah* suka memukul anak,6 I7U 1? tahun=alm3 : si;at (enyabar* dominan mengasuh

anak* tidak ada (erlakuan khusus dalam mengasuhanak,

6 ANAK:+ 8iding 4? tahun3 : (endiam

+ "ahmat 42 tahun3 : suka iri hati

+ Eri

+ #eru 4$ tahun3 : (endiam

+ Neti ) tahun3 : (endiam

+ Ahmad ' tahun3 : (emarah

+ olih & tahun3 : (emalu


8/57


9/57

6 "I-A.A PEKE"0AAN : tidak bekerja

6 "I-A.A PE"KA-INAN : menikah tahun$))* dikarunia $ anak (erem(uan, Sejak

anak di dalam kandungan 1 bulan3 osditinggalkan suami hingga sekarang, Anakos tinggal dengan kakeknya,

6 KEP"I7A8IAN SE7E9U! SAKI :Pendiam* bila ada masalah lebih banyakdi (endam,


10/57

6 KE#I8UPAN PSIK5SEKSUA9 : 5rientasiseks (ada laki+laki,

6 KE#I8UPAN E!5SI5NA9 : 5s mudah

marah dan mudah tersinggung,6 !5"A9 : baik

6 A/A!A : rajin salat

6 S5SIA9 : baik6 #U7UN/AN S5SIA9 : 8engan tetangga

cuku( baik


11/57

Riwayat Penyakit Sekarang

6 Autoanamnesa

6 Keluhan Utama: !arah+marah*memecahkan

kaca6 Sebelum masuk rumah sakit*(asien

memecahkan kaca lemari ketika sedangbertengkar dengan ayah dan kakaknya karena

(asien dilarang buang air besar di luar rumahdan juga karena (asien mengom(ol,

6 ,


12/57

Pasien sering merasa mudah tersinggung

dan ce(at marah terutama ketika

disinggung tentang mengom(ol,Pasien

mengeluh tidak bisa tidur sejak masuk

rumah sakit karena merasa mendengar

suara setan yang mengajak dugem danmenjadi (elacur lagi,Pasien mengaku

(ernah melacurkan diri*sering dugem*dan

mem(unyai $&& orang (acar ketika masihgadis,


13/57

Pasien juga mengaku da(at melihat dan

berbicara dengan setan yang

mengganggu tidurnya,Pasien mengaku

memiliki ilmu (utih yang dida(at dari mbahudin dari jayagiri sejak umur ' thn3

ketika dia (ingsan,Sejak saat itu (asien

merasa mam(u menyembuhkan bayi+bayi


14/57

6 Ketika berada di rumah (asien sering berganti

(akaian setia( ?+$& menit karena (asienmerasa sebagai artis yang harus sering gonta+

ganti baju,Pasien sejak dahulu bercita+cita ingin

menjadi (enyanyi ,Pasien mengaku sebagai

(enyanyi dan telah melakukan rekaman,Pasienjuga merasa sebagai orang kaya dan sering

menam(ung orang+orang miskin di

rumahnya,Pasien mengaku sebagai keturunan

raden cirebon,


15/57

6 Pasien sering merasa sedih ketika berada

di rumah karena teringat akan ibunya

yang telah meninggal (ada tahun 2&&

dan (asien merasa bersalah karena(ernah menendang ibunya,Pada aktu itu

(asien menghukum dirinya dengan

berendam di kamar mandi danmembersihkan dirinya dengan sabun,


16/57

6 Pasien mengaku (ernah melakukan

(ercobaan bunuh diri dengan cara

menusuk (erut dengan gunting sam(ai

berdarah+darah karena kesal ketikabertengkar dengan ayahnya,


17/57

Riwayat Penyakit Dahulu

6 Pasien mengaku (ernah diraat di rumah

sakit jia jalan riau (ada tahun

$)>*$)>?*$)>'*$)>), Alasan (asien

diraat (ertama kali karena (asien seringbernyanyi dan berteriak+teriak (ada

malam hari,


18/57

II. STATUS MENTAL

6 Penamilan

@ Identi;ikasi Pribadi

6 Penderita dijum(ai diruang (eraatan

dalam keadaan tenang* (akaian ra(i dan

bersih* mau menerima jabat tangan dari

(emeriksa* dan sika( terhada( (emeriksa

koo(erati;,

6 Perilaku dan Akti;itas Psikomotor

6 Penderita tam(ak duduk tenang* tidak

banyak bergerak* mata (enderita menata(

ajah (emeriksa,


19/57

!am"aran Umum

6 Kondisi ;isik terlihat cuku( sehat* tidak tam(ak

gelisah* dan ajah tam(ak gembira,6 #i$ara

6 Penderita berbicara dengan jelas dan mudah

dimengerti6 Pikiran %an Persesi

6 7entuk Pikiran

@ Produktiitas : S(ontan* ide cuku(

@ Kelancaran ber(ikir = ide : "eleant

@ /angguan bahasa : idak ada


20/57

Pikiran

7entuk :

0alan : koheren

Isi : + -aham Kebesaran

+ -aham 8osa/angguan Perse(si

#alusinasi: #alusinasi isual dan auditori

melihat dan dengar setan3

Ilusi : idak ada


21/57

Moo% %an A&ek

$, !ood subyekti;3 : biasa2, A;ek obyekti;3 : senang

Sensori$,"oman muka : senang

2,Kesadaran : Kom(os

mentis


22/57

,5rientasi

a, -aktu : idak terganggu

b, em(at : idak tergangguc, 5rang : idak terganggu

4, Konsentrasi B berhitung : Kesan tidak

terganggu

?, Ingatan

a, !asa lalu : idak terganggu

b, !asa kini : idak terganggu

c, Segera : idak terganggu1, Pengetahuan : Sesuai tingkat

(endidikan


23/57

6 III. STATUS 'ISIK

6 Keadaan Umum : Com(os mentis

6 anda Dital :ekanan darah : $&&='& mm#g

Nadi : >4 =menit

"es(irasi : 24 =menitSuhu : 1*) & C

6 Keadaan /iFi : 7aik

6 7entuk ubuh : idak ada de;ormitas

6 Kulit : idak ada kelainan* turgor cuku(


24/57

6 Ke(ala

!ata :

Conjunctia : idak anemis

Sklera : idak ikterik

Pu(il : 7ulat* Isokor G 58S mmPergerakan : 7aik Segala Arah

"e;leks Cahaya : 8 : H=H I : H=H

elinga : idak ada kelainan

!ulut : idak ada kelainan

#idung : idak ada kelainan

6 9eher :

K/7 : tidak teraba membesar

0DP : idak meningkat


25/57

oraks : 7entuk dan gerak simetris

0antung : 7unyi 0antung $ B 2 murni reguler

Paru : D7S kanan J kiri normal "honki : +=+ -heeFing : +=+

Abdomen : 8atar dan lembut

#e(ar : idak teraba

9ien : idak teraba

Ekstremitas : Sianosis +=+* Clubbing +=+ Edema +=+

Kelenjar /etah 7ening : idak membesar

Keadaan Susunan syara;"e;leks %isiologis : H=H

"e;leks Patologis : +=+


26/57

I(. STATUS PSIKIKUS

"oman !uka : senang

Kesadaran : Kom(os mentis

Kontak = "a((ort : Ada = Adekuat

5rientasi : em(at : 7aik

-aktu : 7aik

5rang : 7aik

Perhatian : 7aik

Perse(si : #alusinasi Disual H3

#alusinasi Auditori H3

I t ! ki i 7 ik


27/57

Ingatan : !asa kini : 7aik

!asa dulu : 7aik

Segera : 7aikIntelegensia : "ata+rata

Pikiran : 7entuk : "ealistik

0alan : 7aik Isi : 7aik

Penilaian : Norma sosial : Cuku(

-aham : H3


28/57

I 5 I : 7aik

Emosi : 7aik

8ekorum : So(an santun : 7aik Cara ber(akaian : 7aik

Kebersihan : 7aik

ingkah laku dan bicara : Normoakti;*"elean


29/57

(. DIA!N)SIS MULTIA*IAL

6 Aksis I : % 2?,& /angguan

skiFoa;ekti; ti(e manik

6 Aksis II : idak ada diagnosis

6 Aksis III : idak ada diagnosis

6 Aksis ID : idak ada diagnosis

6 Aksis D : /A% Scale aktu di(eriksa1&+?$ gejala sedang dan disabilitas

sedang3


30/57

(I. REN+ANA TERAPI

carbamaFe(in 2&& mg (,o 2$3

lithium && mg (,o $3


31/57

(II. USUL PEMERIKSAAN

@ Pemeriksaan #b* 9eukosit* kadar gula darah

seaktu

@ Pemeriksaan ureum kreatinin

@ Pemeriksaan S/5 B S/P


32/57

(III. PR)!N)SA

6 uo ad itam : Ad bonam

6 uo ad %unctionam : 8ubia ad bonam


33/57

A;;ectie 8isorder


34/57

8e;inition

6 !ood disorder encom(ass a large grou( o; disorders in hich

(athological mood and related disturbances dominate the clinical

(icture

6 Knon in Diagnostic and Statistical Manual of Mental Disorders

8S!3 as a;;ectie disorders* the term mood disorders is (re;erred

because it re;ers to sustained emotional states* not merely to the

eternal a;;ectie3 e(ressions

6 !ood disorders are best considered syndromes rather than

disease3 consisting o; a cluster o; signs and sym(toms sustained

oer eeks to months* tend to recur* o;ten in (eriodic or cyclic

;ashion


35/57

!ani;estations

6 !ood may be normal* eleated or de(ressed

6 Normal (ersons has a ide range o; moods and are incontrol o; their moods and a;;ects

6 In mood disorders the sense o; control is loss

6 Patients ith an eleated mood demonstratese(ansieness* ;light o; ideas* decreased slee(*heightened sel;+esteem and grandiose ideas

6 Patients ith de(ressed mood sho loss o; energy and

interest* ;eelings o; guilt* di;;iculty in concentrating* losso; a((etite* and thoughts o; death and suicide

6 hese disorders irtually alays results in im(airedinter(ersonal* social and occu(ational ;unctioning


36/57

6 Patients ho hae major de(ressie

e(isode is said to hae major de(ressie

disorder or uni(olar de(ression6 Patients ith both manic and de(ressie

e(isodes or (atients ith manic e(isode

alone are said to hae bi(olar disorder6 #y(omania is an e(isode o; manic

sym(toms that does not meet all the 8S!+

ID criteria ;or manic e(isode


37/57

6 y(es o; mood e(isodes@ !ajor de(ressie e(isode@ !anic e(isode@ !ied e(isode hy(omanic e(isode

6 he main mood disorders@ !ajor de(ressie disorder@ 7i(olar ty(e I

@ 7i(olar ty(e II@ 8ysthymic disorder@ Cyclothymic disorder


38/57

E(idemiology

6 Incidence and (realence

@ !ajor de(ressie disorder has a li;etime (realence o;

$? L in medical (atients

@ 7i(olar I is less common ith a li;etime (realence o;$L

6 Se

@ !anic e(isodes are more common in men@ 8e(ressie e(isodes are more common in omen


39/57

6 Age

@ 5nset o; bi(olar I is earlier that !88

@Age o; onset in bi(olar I ranges ;rom

childhood to ?& years* ith mean age o; &

@ !ean age o; !88 is about 4& years

6 !arital status

@ !88 occurs most o;ten in (ersons ithout

close inter(ersonal relationshi(s or in thoseho are diorced or se(erated


40/57

Course and Prognosis

6 Untreated manic e(isodes generally lastabout months

6 he course is usually chronic ith

rela(ses as the disease (rogresses*e(isodes may occur more ;reMuently

6 7i(olar disorder has a orse (rognosis

than !88* as only ?&+1&L o; (atientstreated ith lithium e(erience signi;icantim(roement in sym(toms


41/57

reatment

6 Pharmacothera(y

@ 9ithium @ mood stabiliFer

@Anticonulsants eg, CarbamaFe(ine or al(roic acid3

6 Psychothera(y

@ Su((ortie thera(y* ;amily thera(y

6 EC

@ -orks ell in treatment o; manic e(isodes


42/57

SchiFo(hrenia

6 A (sychiatric disorder characteriFed by aconstellation o; abnormalities in thinking*emotion and behaior

6 In general the sym(toms o; schiFo(hreniaare broken u( in 2 categories:@ Positi,e symtoms: hallucinations*

delusions* biFarre behaior or thought disorder

@ Negati,e symtoms: blunted a;;ect*anhedonia* a(athy and inattentieness


43/57

According to Eugen 7leuler* sym(toms include

associational disturbances* a;;ectie disturbance*

autism and ambialence

According to Emil Krae(lin described (atients haing a long

term deteriorating course and the common clinical

sym(toms o; hallucinations and delusions

9ang;edlt classi;ied (atients ith major (sychotic

sym(toms into 2 grou(s* those ith true schiFo(hrenia

and those ith schiFo(hrenialike (sychosis,


44/57

Etilogy

A, Stress+diathesis !odel

A (erson may hae a s(eci;ic ulnerability

diathesis3 that* hen acted on by a stress;ul

in;luence* allos the sym(toms o;schiFo(hrenia to deelo(

7, 8o(amine #y(othesishis theory (osits that schiFo(hrenia results

;rom too much do(aminergic actiity


45/57

C, Neuro(athology

6 neuro(athological and neurochemical abnormalities in

the cerebral corte* the thalamus and the brainstem6 9oss o; brain olume in schiFo(hrenic (atients a((ear to

result ;rom reduced density o; the aons*dendrites and

syna(ses

8, /enetic %actors

6 A (erson is likely to hae schiFo(hrenia hen other

members o; the ;amily hae the disorder

6 9ong arm o; chr ?* $$ and $>* the short arm o; chr $)*and chromosomes


46/57

E, Psychosocial %actor

6 %reud (ostulated that schiFo(hrenia results ;romdeelo(mental ;iations that occurred early in the

deelo(ment o; neuroses,6 Ego disintegration in schiFo(hrenia re(resents a return

to the time hen ego as not yet deelo(ed, husintra(sychic con;lict arising ;rom the early ;iations andthe ego de;ect* hich may hae resulted ;rom (oor earlyobject relations* ;uel the (sychotic sym(toms,

6 he ego de;ect a;;ects the inter(retation o; reality andthe control o; inner dries, he disturbance results ;romdistortions in the relationshi( beteen in;ant and the

mother6 o #enry Sullian* schiFo(hrenia is an ada(tie method

to aoid (anic* terror and disintegration o; the sense o;sel;


47/57

8iagnosis 8S!+ID3

A, Characteristic sym(toms: 2 or more o; the

;olloing each (resent ;or a signi;icant (ortion

o; time during a $ month (eriod

$, 8elusions2, #allucinations

, 8isorganiFed s(eech

4, /rossly disorganiFed or catatonic behaior

?, Negatie sym(toms* ie,*a;;ectie ;lattening* alogia*or aolition


48/57

7, Social= 5ccu(ational dys;unction

C, 8uration

6 continuous signs ;or at least 1 months

6 his 1 month (eriod must include at least $

month o; sym(toms and may include (eriods o;

(rodromal or residual sym(toms

8, SchiFoa;;ectie and mood disorder eclusion

E, Substance= general medical condition eclusion

%, "elationshi( to a (erasie deelo(mentaldisorder


49/57

Subty(es

6 Paranoid y(e

6 8isorganiFed y(e

6Catatonic y(e

6 Undi;;erentiated y(e

6 "esidual y(e


50/57

reatment

6 #os(italiFation

6 Pharmacothera(y@ 8o(amine rece(tor antagonist

@ Serotonin+do(amine antagonist@ 5ther drugs: lithium* anticonulsants

6 Psychosocial thera(ies@ Social skills training

@ %amily+oriented thera(y@ /rou( thera(y

@ Cognitie behaioral thera(y


51/57

ShciFoa;;ectie 8isorder


52/57

8e;inition

6 $)+ 0acob Kasanin introduced the term

schiFoa;;ectie disorder to re;er to a

disorder ith sym(toms o; both

schiFo(hrenia and mood disorders


53/57


54/57

8S!+ID 8iagnostic Criteria ;or

SchiFoa;;ectie 8iorder

A, An uninterru(ted (eriod o; illness during hich* at some time*

there is either a major de(ressie e(isode* or a mied e(isode

concurrent ith sym(toms that meet criterion A ;or schiFo(hrenia

7, 8uring that same (eriod o; illness* there hae been delusions or

hallucinations ;or at least 2 eeks in the absence o; (rominent

mood sym(toms

C, Sym(toms that meet the criteria ;or a mood e(isode are (resent

;or a substantial (ortion o; the total duration o; the actie and

residual (eriods o; the illness

8, he disturbance is not due to the direct (hysiological e;;ects o; a

substance or a general medical condition


55/57

Course and Prognosis

6 Considering the uncertainty and eoling

diagnosis o; schiFoa;;ectie disorder*

determining the long+term course and

(rognosis is di;;icult6 An increasing (resence o; schiFo(hrenic

sym(toms (redicted orse outcome


56/57

reatment

6 !ood stabiliFers @ mainstay o; treatment

6 CarbamaFe(ine

@ 7inds to oltage+de(endent Na channels in

inactie stage (rolonging inactiation

reduces Ca channel actiation

reduce syna(tic transmission

@Aderse e;;ect: rash* leuko(enia


57/57

6 9ithium@ hera(eutic mechanism o; action ;or lithium

remains uncertain

6 Used alone* in combination ith eachother

6 In manic e(isodes* schiFoa;;ectie(atients should be treated aggressielyith dosage in the middle to high, As(atient enters maintenance (hase*dosage can be reduced to lo to middlerange to aoid aderse e;;ects