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SKIZOFRENIA DAN

PENYAKIT JIWA
LAINNYA
dr liza (140 366
660)
Indonesia AND
Kognitif
KIRI Pragmati Kanan
ATAS k atas

Logis Konseptual
Kuantitatif Sintesis
Kritis Metaforis
Visual
Analitis Integrative
Factual Whole Brained

Realistis Kreatif Idealistis


Common Natural Kinestetik
Sense

Sekuensial Emosional
Terkontrol Indriawi
Konservatif Humanistik
Struktural
Mendetail
Musical
Ekspresif
Kiri Kanan
bawah Intuitif bawah
Instingtif
 Regional Functions of the
Human Brain
 Frontal lobes
   Voluntary movement
   Language production (left)
   Motor prosody (right)
   Comportment
   Executive function
   Motivation
Temporal lobes
   Audition
   Language comprehension (left)
   Sensory prosody (right)
   Memory
   Emotion
Parietal lobes
   Tactile sensation
   Visuospatial function (right)
   Reading (left)
   Calculation (left)
Occipital lobes
   Vision
   Visual perception
KELUHAN UTAMA

PSIKOSOMATIK KELUHAN BERKAITA


KELUHAN FISIK DENGAN MASALAH
BERKAITAN ALAM PERASAAN
DENGAN PSIKIS PIKIRAN
5. JANTUNG DEBAR PRILAKU
FISIK 6. DARAH TINGGI F. PSIKOSIS
APAKAH 7. ULU HATI SAKIT, G.ANXIETAS
MURNI/ 8. DIARE H. DEPRESI
FISIK GANDA 9. GATAL/EKSIM I. ZAT
10.ASMA J. RETARD MENT
11.KEPUTIHAN K. EPILEPSI
12.BANYAK KERINGAT L. GANGGUAN PERK
13.GANGGUAN HAID ANAK DAN REMAJA
PERTANYAAN AKTIF BILA ADA KEL
PSIKOSOMATIK, MENTAL EMOSIONAL,
DAN G FISIK GANDA DENGAN G.
MENTAL EMOSI
 ADA DISTRESS (DIRI, LINGK, DAN
ATAU KELUARGA)
 ADA GANGGUAN FUNGSI
PEKERJAAN/AKADEMIK, SOSIAL DAN
SEHARI HARI
 KHUSUS ANAK ADA GANGGUAN
PERKEMBANGAN, MASIH NGOMPOL,
TERLALU NAKAL, GANGGUAN
MAKAN, KESULITAN BELAJAR, TAK
MAU SEKOLAH, SERING MELARIKAN
DIRI
BILA DISERTAI GANGGGUAN
ORGANIK TAPI PERTANYAAN
DIATAS TIDAK ADA DISTRES
 DEMESIA (0801) FO
 DELIRIUM (0801) FO
 G. PSIKOSOMATIK (0802) F5
 G. PENGGUNAAN ZAT (0805) F1
 G. RETARDASI MENTAL (0803) F
7
 EPILEPSI (0901) G 38
PERTANYAAN AKTIF YA TANPA
KELAINAN ORGANIK
 G, PSIKOSOMATIK (0801) F2
 G. DEPRESI (0802) F3
 G, CEMAS (0802) F4
 G. KESEHATAN JIWA ANAK DAN
REMAJA (0804) F8 F9
 G. KEPRIBADIAN (0805) F5 F6
0801 GANGGUAN PSIKOTIK
 GANGGUAN MENTAL ORGANIK
 SKIZOFRENIA DAN GANGGUAN
WAHAM
 GANGGUAN SUASANA PERASAAN
DALAM BENTUK PSIKOTIK
GEJALA PSIKOTIK
 WAHAM =KEYAKINAN MENETAP YANG TIDAK
SESUAI DENGAN KENYATAAN DAN SELALU
DIPERTAHANKAN
 HALUSINASI = PERSEPSI PANCAINDERA TANPA
SUMBER RANGSANGAN SENSORIK EKSTERNAL
SEPERTI MENDENGAR BISIKAN, MELIHAT
BAYANGAN
 INKOHERENSI = PEMBICARAAN KACAU/ TULISAN
YANG TIDAK DIMENGERTI
 KATATONIA = GANGGUAN PSIKOMOTOR 
STUPOR (TIDAK BERGERAK). MUTISME (TAK
BICARA), FUROR (GADUH GELISAH), NEGATIVISME
(MENENTANG). POSITIONING (BERTAHAN DALAM
POSISI TERTENTU). RIGIDITAS (KEKAKUAN
TUBUH). FLEKSIBILITAS LILIN (POSISI DAPAT
DIATUR OLEH PEMERIKSA SEOLAH BERBENTUK
LILIN), OTOMATISME PERINTAH (PERINTAH
DILAKSANAKAN SECARA OTOMATIS TANPA
BERFIKIR LAGI)
TANDA/ GEJALA ORGANIK
 FAKTOR ORGANIK SPESIFIK YANG
DIDUGA ADA KAITAN DENGAN KEJIWAAN
TRAUMA, TOKSIN, PENYAKIT FISIK
BERKAITAN DENGAN SSP SEPERTI
PANAS TERLALU TINGGI, PENYAKIT FISIK
YANG MENIMBULKAN GANGGUAN
METABOLISME PADA OTAK
 PENURUNAN KESADARAN PATOLOGIK,
APATIS, APATIS, SOMNOLEN, SOPOR,
KOMA, DELIRIUM.
GANGGUAN FUNGSI
INTELEK/KOGNITIF
 TARAF KECERDASAN MENURUN :
BERKURANGNYA KEMAMPUAN UNTUK
MENGGUNAKAN HAL HAL YANG TELAH
DIPELAJARI
 DISORIENTASI : GANGGUAN PEMAHAMAN
TERHADAP LINGKUNGAN (DISORIENTASI
WAKTU, TEMPAT, DAN ORANG)
 GANGGUAN DAYA INGAT: LUPA AKAN
HAL-HAL YANG TELAH TERJADI
Anatomi otak
 DEMENSIA (F0) KESADARAN SENSORIUM
BAIK, GANGGUAN DAYA INGAT, USIA >
60 TH (DEMENSIA PRESENILIS)
KADANG2 DISERTAI DISORIENTASI
 DELIRIUM (F0) KESADARAN BERKABUT,
GELISAH, BISA DISERTAI HALUSINASI
VISUAL , DISORIENTASI
 SKIZOFRENIA DAN GANGGUAN WAHAM,
GEJALA PSIKOTIK, BERLANGSUNG LEBIH
DARI 1 BULAN, TANPA GANGGUAN
KOGNITIF
 GANGGUAN SUASANA PERASAAN
TERUTAMA GEJALA AFEKTIF SEPERTI
EPISODE DEPRESI ATAU EPISODE MANIK
0802 GANGGUAN NEUROTIK
 G. NEUROTIK DENGAN AFEK CEMAS,
GANGGUAN CEMAS, FOBIA, OBSESI
KOMPULSI, PANIK, GANGGUAN STRES
PASCA TRAUMA (F4)
 GANGGUAN NEUROTIK DENGAN AFEK
DEPRESI, GANGGUAN DEPRESI (F3)
GANGGUAN STRESS PASCE TRAUMA (F4)
 GANGGUAN NEUROTIK DENGAN KELUHAN
FISIK GANGGUAN PSIKOSOMATIK (F5) ,
GANGGUAN SOMATOFORM (F4)
PEDOMAN DIAGNOTIK
 GANGGUAN NEUROTIK (DENGAN AFEK CEMAS)
* AFEK/MOOD: SUASANA ALAM PERASAAN YANG
RELATIF MENETAP, YANG SERING
MEMPENGARUHI PERILAKU DAN PERSEPSI
INDIVIDU AKAN DUNIA LUAR SEPERTI CEMAS
DAN DEPRESI
* CEMAS : RASA KAWATIR YANG BERLEBIHAN
DISERTAI DENGAN KETEGANGAN MOTORIK
(TEKANAN DARAH MENINGKAT, PUSING2,
PEGAL2) HIPERAKTIFITAS AUTONOM, (KERINGAT
DINGIN, BERDEBAR, SESAK NAFAS, SAKIT
PERUT) DENGAN/TANPA DIDAHULUI STRESOR
YANG BERMAKNA)
 FOBIA :KETAKUTAN IRASIONAL YANG
MENETAP TERHADAP SUATU
OBJEK/SITUASI
1.FOBIA SOSIAL : TAKUT DIPERHATIKAN,
SALAH TINDAK
2. AGORAFOBIA: FOBIA TERHADAP
KERAMAIAN DAN KESENDIRIAN
3. KLAUSTROFOBIA: FOBIA TERHADAP
RUANG TERTUTUP
4. AKROFOBIA: FOBIA TERHADAP
KETINGGIAN
5. AICHMOFOBIA : FOBIA TERHADAP BENDA
TAJAM
 OBSESI: PIKIRAN BERULANG YANG
TIDAK BISA DIHINDARKAN
 KOMFULSI: PERBUATAN BERULANG
YANG TIDAK BISA DIHINDARKAN
 PANIK: SERANGAN ANXIETAS BERAT
DALAM KEADAAN DIMANA TIDAK ADA
BAHAYA
 GANGGUAN STRESS PASCA TRAUMA:
ANXIETAS YANG TERJADI DALAM KURUN
WAKTU 6 BULAN SETELAH SUATU
KEADAAN TRAUMATIK YANG SANGAT
BERAT
GANGGUAN NEUROTIK DENGAN AFEK
DEPRESI
 DEPRESI : RASA SEDIH YANG BERLEBIHAN DAN
BERKEPANJANGAN , DISERTAI DENGAN
GANGGUAN FUNGSI PEKERJAAN, FUNGSI SOSIAL
DAN PERAWATAN DIRI
 GEJALA DEPRESI :
RASA SEDIH, MURUNG, PUTUS ASA, RENDAH
DIRI
KEHILANGAN GAIRAH KERJA, BELAJAR, GAIRAH
SEX, LESU, AKTIFITAS BERKURANG
GANGGUAN MAKAN (TIDAK NAFSU
MAKAN/BERLEBIHAN, GANGUAN TIDUR (SULIT/
TERLALU BANYAK TIDUR)
MENYENDIRI, TAK SUKA BERGAUL, KURANG
KOMUNIKASI
GANGGUAN NEUROTIK dgn kel fisik
 Keluhan fisik: semua keluhan fisik dengan
/tanpa kelainan organik yang
melatarbelakangi oleh faktor psikologik
(berupa afek anxietas atau depresi)
 Bentuk keluhan fisik= cefalgia,
hipertensi, asma bronkial, gastritis, kolitis
kronik, rematik, dermatitis
 Faktor psikososial: masalah keluarga,
lingkungan sosial, pendidikan, pekerjaan,
perumahan, ekonomi, politik, hukum dan
lain2
RETARDASI MENTAL (F7) 0803
 KECERDASAN IQ <70
 KEMAMPUAN ADAPTASI KURANG
 DIDAPATKAN PADA USIA <18 TH
 PEMBAGIAN
RM RINGAN IQ 50-69
RM SEDANG IQ 35-49
RM BERAT IQ 20-34
RM SANGAT BERAT IQ <20
CONTOH UMUR 8 TH, KECERDASAR 4 TH,
IQ = 4/8 X 100 = 50
0804 GANGGUAN KESEHATAN JIWA
PADA BAYI ANAK DAN REMAJA
 GANGGUAN PERKEMBANGAN
BERBICARA, BERBAHASA, BELAJAR,
MOTORIK (F8)
 GANGGUAN PERKEMBANGAN PERVASIF
(F8)
 GANGGUAN HIPERKINETIK (F9)
 GANGGUAN TINGKAH LAKU (F9)
 GANGGUAN EMOSIONAL (F9)
 GANGGUAN FUNGSI SOSIAL (F9)
 GANGGUAN “TIC” F9
0901 EPILEPSI 640
 TANDA-TANDA = KESADARAN
MENURUN/BERUBAH
 AURA (SENSASI SBELM TIMBULNYA
SERANGAN): BISA ADA ATAU TIDAK ADA
 KEJANG UMUM, FOKAL, ATAU TIDAK ADA
KEJANG
 SERANGAN BERULANG DAN EPISODIK
 GEJALA : FISIK / PSIKIS
 TERMASUK GRANDMAL, PETITMAL,
PSIKOMOTOR, FOKAL MOTOR
 EPILEPSI EKIVALEN MISAL SAKIT PERUT
PERIODIK, KEJANG DEMAM PADA
TERAPI BIOLOGIS
MEDIKAMENTOSA
 ANTI PSIKOTIK/NEUROLEPTIKA
 1. GOL POTENSI RENDAH DENGAN
DOSIS EFEKTIF > 100 MG/HR) DAN
MEMPUNYAI EFEK SEDASI KUAT
MISALNYA
- GOL TIPIKAL: CHLORPROMASONE 100
THIORIDAZINE 100
-GOL ATIPIKAL : QUETIAPINE 100
CLOZAPINE 100
 GOLONGAN DENGAN POTENSI TINGGI
(DGN DOSIS EFEKTIF <100 MG/HR) DAN
MEMPUNYAI EFEK SEDASI RINGAN
MISALNYA
- TIPIKAL :
1. FLUFENAZINE 5 MG
2. TRIFLUOPERAZINE 5 MG
3. PERPHENAZINE 4 MG
4. HALOPERIDOL 2 MG
- ATIPIKAL
1. RISPERIDONE 1 MG
2. OLANZAPINE 5 MG
DOSIS THERAPEUTIK ANTI
PSIKOTIK
 CHLORPROMAZINE (GENERIK 25 MG, 100 MG
PERTAB) 150-1800 MG/R (3X50-600MG)
 DOSIS AWAL 25 MG X 3/HR ATAY 75 MG
MALAM,
 ANAK SKIZP-AUTISME, 1-5 TH, 500 MCG/KG
SETIAP 4-6 JAM.(MAKS 40 MG/HR), 6-12 TH,
1/3-1/2 DWS.
 GEGUKAN YANG SULIT DIOBATI 25 MG X 3
** CEPEZET (TABCO 100 MG, AMP 50MG/2ML)
DOSIS ADULT 10-20 MG EVERY 4-6 HOURS,
PSiCHOSIS 200-800 MG DAILY, CHILDREN 0,5
MG/KGBB EVERY 4-6 HRS
**MEPROSETIL (FILOTAB 25 MG, 100 MG)
**PROMACTIL (FILM CO TAB 100 MG)
KLORPROMAZIN
 HINDARI KONTAKHIDROKLORIDA
LANGSUNG
 PERINGATAN: PENYAKIT KARDIOVASKULAR, DAN
SEREBROVASKULAR, PENYAKIT PERNAFASAN, PARKINSONISM,
EPILEPSI, INFEKSI AKUT, HAMIL, MENYUSUI, GANGGUAN GINJAL,
HATI, RIWAYAT KUNING LEUKOPENIA, HIPOTIROIDISME,
HIPERTROPI PROSTAT, HATI HATI PADA PS USILA, HINDARI
PEMUTUSAN OBAT MENDADAK, SETELAH INJEKSI IM PS HARIS
TETAP TIDURAN 30 MNT
 KONTRAINDIKASI: KOMA KRN DEPRESAN SSP, DEPRESI SUMSUM
TULANG, HINDARI PADA FEIKROMOSITOMA, GANGGUAN HATI DAN
GINJAL BERAT
 EFEK SAMPINGl GEJALA EKSTRAPIRAMIDAL, TARDIVE DYSKINESIA,
HIPOTERMIA, KADANG KADANG PANAS, MENGANTUK, APATIS,
PUCAT, BERMIMPI BURUK, INSOMNIA, DEPRESI, AGITASI,
PERUBAHAN EEG, KEJANG PADA GEJALA ANTI MUSKARINIK YANG
TERDIRI ATAS : MULUT KERING, HIDUNG TERSUMBAT, KONSTIPASI,
KESULITAN BUANG AIR KECIL, PANDANGAN KABUR, GEJALA
KARDIOVASKULAR, MELIPUTI HIPOTENSI, TAKIKARDIA, ARITMIA,
TERJADI PERUBAHAN EKG, PENGARUH ENDOKRIN SEPERTI GG
MENSTRUASI, GALAKTORE, GINEKOMASTIA, IMPOTENSI,
PERUBAHAN BB, TERJADI REAKSI SENSITIVITAS,
AGRANULOSITOSIS, LEUKOPENIA, LEUKOSITOSIS, ANEMIA
HEMOLITIK, FOTOSINTESIS, SENSITISASI KONTAK, RUAM, SAKIT
KUNING, PERUBAHAN FUNGSI HATI, SINDROM NEUROLEPTIK
 THIORIDAZINE 100-800 MG/HR
(2X50-400MG)
**MELLERIL @ TAB (50 MG), 100 MG D
DOSIS MELLERIL ANXIOLITIC ANTIDEPRESAN
ADULT 10-75 MG DAILY,
CHILDREN ADJUCTIVE THERAPY IN
CONCDIFFICULTIES, BEHAVIOUR DISORDERS,
HIPERACTIVITY, AGGRESSIVENESS, SLEEP
DISTURBANCES, 0,5 – 2 MG/KGB DAILY
ALCHOHOLIC PATIENTS DURING WITHDRAWAL
100 -200 MG DAILY
SEVERE NEUROSIS 25-15- MG DAILY MAX 800 MG
DAILY
CHILDREN CHILDHOOD SCHIZOFRENIA, SEVERE
BEHAVIOURAL DISORDERS IN MENTAL
RETARDATION AND PSYCHOPATHY 1-4 MG/KG
DAILY IN DIVIDED DOSES
HALOPERIDOL 1,5 MG-30 MG/HR (3X0,5-10MG)
 HALDOL 2 MG, 5 MG  DOSIS NERVOUSNESS,
ANXIETY STATES, TICS, STUTTER GI UPSET 0,5
MG 2 TIMES DAILY
 Ederly 0.5-2 mg 2-3 times daily
 MANIA , ACUTE AND CHRONIC SCHIZOFRENIA,
PARANOIA, BEHAVIOR & CHARACTER DISORDER IN
CHILD MODERATE 0,5 – 2 MG 2-3 TIMES DAILY. Severe
3-5 mg 2-3 times daily
 Children 3-12 yr 0.05-0.15 mg/kgbb in divided
dose
 Chronic schizofrenia adult&child >12 y initialy
6-15 mg in 2-3 divided dosis
 Eat with meals to minimise gi imtation
DORES (1,5 MG, TAB), CAP 5 MG
Govotil tab 2 mg, tab 5 mg
Haldol decanoas ampul 50 mg/ml (1 ml),
RISPERIDONE
 I:acute & chronic schizophrenia & other
psychotic condition, alleviates affective
symptoms associated with
schizophrenia
 D: 1 st day 2 mg daily un 1-2 divided
doses
2nd day 4 mg daily 1-2 divided doses
3rd day 6 mg daily in 102 divided
doses
General doses 4-8 mg daily
Eiderly renal, hepatic disease initial 0,5
mg twice daily doses maybe increased
RISPERIDONE
 INDIKASI : SKIZOFRENIA AKUT & KRONIK
 PERINGATAN: PENYAKIT KARDIOVASKULAR
BILA TERJADI HIPOTENSI DOSIS
DITURUNKAN, INSUFISIENSI GINJAL, HATI,
USIA LANJUT PARKINSONISME, EPILEPSI,
MENGEMUDI, MENJALANKAN MESIN,
HAMIL, MENYUSUI, PANTAU TANDA
TARDIVE DYSKINESIA
 EFEK SAMPING : INSOMNIA, AGITASI,
ANSIETAS, NYERI KEPALA, PUSING,
SOMNOLEN, LESU, DISPEPSIA, MUAL,
NYERI ABDOMEN, GEJALA
EKSTRAPIRAMIDAL
 RISPERDAL 1,2,3 MG
Aripiprazol
 ABILIFY @
I : SCHIZOFRENIA
D: 10 OR 15 MG ONCE DAILY
SP: REDUCE OR DISCONTINUE DOSE IF SIGN
OR SYMPTOMS OF TARDIVE DYSKENESIA,
NEUROLEPTIC MALIGNANT SYNDROME
APPEAR, HISTORY OF SEIZURE,
PREGNANCY & LACTATION, MAY IMPAIR
ABILITY TO DRIVE OR OPERATE
MACHINERY
AR: HEADACHE, NAUSEA, VOMITING,
CONSTIPATION, ANXIETY, INSOMNIA,
LIGHTHEADEDNESS, SOMNOLENCE,
CLOZAPINE
 CLORILEX TAB 25 MG, 100 MG
 CLOZARIL TAB 25 MG, 100 MG
 LUFTEN
 DOSIS : 12,5 MG ONCE OR TWICE
DAILY ON THE 1 ST DAY, FOLLOWED
BY STEPWISE INCREASE W/DAILY
INCREMENTS DOSES MAX 600
MG/DAY EXCEPTIONS 900 MG
OLANZAPINE
 ZYPREZA TAB 5 MG, 10 MG, VIAL 10 MG
 DOSIS: TAB SCHIZOPHRENIA & RELATED
DISORDERS STARTING DOSE 10 MG/DAY
 MANIC EPISODES STARTING DOSE 15 MG/DAY
AS A SINGLE DOSE IN MONOTHERAPY OR 10
MG/DAY IN COMBINATION WITH LITHIUM OR
VALPROATE
 PREVENTING RECURRENCE IN BIPOLAR
DISORDER 10 MG.DAY
 DURING TREATMENT FOR BOTH
SCHIZOPHRENIA & MANIC EPISODES DAILY
DOSAGE SUBSEQUENTLY BE ADJUSTED
ACCORDING TO CLINICAL RESPONSE WITHIN
THE RANGE 0F 5-20 MG/DAY . VIAL 10 MG AS
APG II DOSIS THER FREK DOSI KEUNTUNGAN KERUGIAN
AWAL MG/HR S
MAKS

CLOZA 25-50 300- 2X/HR 900 SKISOFRENIA AGRANULUS


REFRAKTER , EPS ITOSIS, BB
PINE 600
RENDAH NAIK,
KEJANG

OLAN 5- 10 15-20 1 20 DITOLERANSI BERAT


DENGAN BAIK, BADAN
ZAPIN X/HR
EFEKTIF UNTUK NAIK
E MANIA AKUT
QUE 25 -50 400- 2–3 800 DITOLERANSI TITRASI
600 X/HR DENGAN BAIK DOSIS
TIAPI
RESIKO EPS RENDAH SEDASI
DINE

RISPE 1-2 4-8 2X/H 16 DITOLERANSI DGN DOSIS


BAIK TERGANTUN
RIDO R
WELL DEFINED DOSE G EPS
NE RANGE

ZIPRA 40-80 80- 2X/HR 160 DITOLERANSI QT


SIDON 160 DENGAN BAIK PROLONGE
E BB TIDAK , BERSAMA
NAIK’ADA INJ MAKANAN
APG 1 DOSIS/ ORAL WAKTU EFEK SAMPING
HR PARUH
JAM
HALO 5-20 MG 2 MG 12-36 EPS +++, SEDASI +,
PERI (2X/HR) OTONOM +
DOL
TRI 5-30 MG 5 MG - EPS +++, SEDASI
FLUO (2x/HR) ++. OTONOM +
PERA
ZINE
CHLOR 200-600 100 8-35 SEDASI +++,
PROMAZIN MG MG OTONOM +++, EPS
E (2X/HR) +
FLUPHENA 2-20 MG 2 MG 14-24 EPS +++, SEDASI +
ZINE (2-3x/HR) OTONOM +

THIORIDAZI 200- 100 9-30 EPS +++, SEDASI +,


NE 600MG OTONOM +
SULPIRIDE 2X/HR
400-2400 400 - -
(2x)
GAMBA JENIS OBAT EFEK KLINIS OBAT TERSEBUT
RAN MEMBERI
NEURO GAMBARAN GEJALA
TRANS SEPERTI
SKIZOFRENIA
MITER
O/OBAT
DOPA AMFETAMIN EKSITASI, GEJALA POSITIF,
MIN MENYEBABKAN PENINGKATAN HALUSINASI,
PELEPASAN DAN INSOMNIA, TERUTAMA
MENCEGAH REUPTAKE HALUSINASI, PENGLIHATAN,
(PENGAMBILAN KEWASPADAAN, PERABAAN,
KEMBALI DARI HOSTILITAS, WAHAM KEJAR
DOPAMIN KETERGANTUNGAN
SEROTO LSD, ANTAGONIS EKSITASI, INSOMNIA, GEJALA POSITIF
NIN PARSIAL AGONIS DI EUFORIA, HALUSINASI DISFORIK,
RESEPTOR 5HT2A DAN VISUAL, PARANOIA, PERUBAHAN
5HT2C, PELEPASAN KETERGANTUNGAN MOOD, IDEAS OF
NMDA DAN REFERENCE, AFEK
PENCEGAHAN YANG TIDAK
REUPTAKE SEROTONIN SERASI,
DARI SINAP CONCRETE
GLUTA KETAMIN DAN PCP ANESTESI, DISTORSI THINGKING
GEJALA POSITIF
MAT ANTAGONIS RESEPTOR DARI BODY IMAGE, DAN NEGATIF:
KETERGANTUNGAN, NEGATIVISME,
NMDA
EKSITASI, APATIS, DEFISIT
HALUSINASI KOGNITIF
Tri heksifenidil
 Indikasi : parkinsonisme, gangguan ekstrapiramidal
karena obat kecuali tardive dyskinesia
 Peringatan, penyakit kardiovaskular, hati , ginjal,
hindari pemutusan obat mendadak, usila
 Kontra indikasi: retensi urin, glukoma (sdt sempit),
obstruksi sal cerna
 Efek samping, mulut kering, gangguan pencernaan,
pusing , penglihatan kabur, retensi urin, takikardia,
hipersensitiv, gugup, dosis tinggi pada pasien yang
peka, bingung, eksitasi, gangguan jiwa
 Dosis 1 mg/hr dinaikan bertahap, dosis
pemeliharaan 5-15 mg/hr terbagi 3-4 kali . Usua
lanjut dosis dibawah kisaran dosis
 Generik tryhexyphenidil tab 2 mg, 5 mg
 Arkine kaptab 2 mg, artane tab 2 mg, parkinal tab 2
mg
DIAZEPAM
 I: PEMAKAIAN JANGKA PENDEK PD ANSIETAS, ATAU INSOMNIA,
TAMBAHAN PADA PUTUS ALKOHOL AKUT, STATUS EPILEPTIKUS,
KEJANG DEMAM SPASME OTOT
 PERINGATAN: DAPAT MENGGANGGU KEMAPUAN MENGEMUDI.
HAMIL, MENYUSUI, USILA LANJUT, PENYAKIT HATI, GINJAL, PENYAKIT
PERNAFASAN, KELEMAHAN OTOT, RIWY KEPRIBADIAN NYATA,
KURANGI DOSIS, PADA USIA LANJUT, DEBIL NYATA, HINDARI
PEMAKAIAN JANGKA PANJANG, PERINGATAN KHUSUS UNTUK INJEKSI
 KONTRAINDIKASI: DEPRESI, PERNAFASAN, GANGGUAN HATI BERAT,
MIASTENIA GRAVIS, INSUFISIENSI PULMONER AKUT, KONDISI FOBIA,
OBSESI, PSIKOSIS KRONIK, GLUKOMA SDT SEMPIT AKUT, SERANGAN
ASMA AKUT, TRIMESTER PERTAMA KEHAMILAN, BAYI PREMATUR,
TIDAK BOLEH DIGUNAKAN SENDIRIAN PADA DEPRESI ATAU
ANSIETAS DENGAN DEPRESI
 EFEK SAMPING: NGANTUK, KELEMAHAN OTOT, ATAKSIA, REAKSI
PARADOKSAL DALAM AGRESI, GANGGUAN MENTAL, AMNESIA,
KETERGANTUNGAN, DEPRESI NAFAS, KEPALA LEBIH RINGAN HARI
BERIKUTNYA, BINGUNG. KADANG TERJADI NYERI KEPALA, VERTIGO,
HIPOTENSI, PERUBAHAN SALIVA, GANGGUAN SAL CERNA, RUAM,
GANGGUAN PENGLIHATAN, PERUBAHAN LIBIDO, RETENSI URIN,
DILAPORKAN KELAINAN DARAH DAN SAKIT KUNING
 PADA INJEKSI IV TERJADI NYERI , TROMBOFLEBITIS, JARANG
APNEU/HIPOTENSI
 DOSIS : ORAL ANSIETAS 2 MG 3 X/HR, DINAIKAN
KALAU PERLU SAMPAI 15-30 MG/HR DALAM DOSIS
TERBAGI
 UNTUK USILA ATAU DEBIL DOSIS 1/2NYA
 INSOMNIA DISERTAI ANSIETAS 5-15 MG SBLM
TIDUR
 INJEKSI IM. INJEKSI IV LAMBAT KEDALAM VENA
YANG BESAR DENGAN KECEPATAN TIDAK LEBIH
DARI 5 MG/MNT) UNTUK ANSIETAS AKUT BERAT,
PENGENDARILIAN SERANGAN PANIK AKUT, DAN
PUTUS ALKOHOL AKUT : 10 MG DIULANGI BILA
PERLU,SETELAH TIDAK KURANG 4 JAM
 DIAZEPAM GENERIK 2 MG, 5 MG TAB
 STESOLID INJ 10 MG/2 ML, ENEMA 5 MG.2,5 ML,
10 MG/2,5 ML. SIRUP 2 MG/5 ML. TAB 2 MG, TAB 5
MG
 VALIUM INJ 5 MG/ML. TAB 2 MG, TAB 5 MG
 VALISANBE 2 MG , 5 MG TAB
SKIZOFRENIA
SEJARAH
 EMIL KRAEPELIN (1856-1926)= DEMENSIA
PREKOKS, (DEMENSIA PADA USIA DINI),
DITANDAI DENGAN PROSES KOGNITIF
YANG MAKIN LAMA MAKIN MEMBURUK
DAN DISERTAI DENGAN GEJALA KLINIS
BERUPA HALUSINASI
 EUGEN BLEULER (1957-1939)
SKIZOFRENIA TERJADINYA PERPECAHAN
ANTARA PIKIRAN, EMOSI DAN PERILAKU 4
A: ASOSIASI, AFEK TERGANGGU, AUTISME,
AMBIVALENSI, DITAMBAH WAHAM DAN
HALUSINASI
 GABRIEL LANGFELDT- MEMBAGI GJL
PSIKOTIK ADA 2 KELOMPOK, TRUE
SCHIZOPHRENIA ( DEPERSONALISASI,
AUTISME, EMOSI TUMPUL, DAN
 KRITERIA DIAGNOSIS MENURUT LANGFELDT
 1. KRITERIA SIMPTOM, MERUPAKAN PETUNJUK
PENTING UNTUK MENDIAGNOSIS SUATU
SKIZOFRENIA, DAPAT DIGUNAKAN BILA TIDAK
DITEMUKAN ADANYA TANDA2 BERUPA
GANGGUAN KOGNITIF, INFEKSI, INTOKSIKASI,
MELIPUTI
 1. PERUBAHAN KEPRIBADIAN, BERUPA EMOSI
YANG TUMPUL, DIIKUTI DENGAN HILANGNYA
INISIATIF, DAN PERUBAHAN PERILAKU
SEHINGGA PENDERITA TERLIHAT ANEH
 2. TIPE KATATONIK , KEGELISAHAN & STUPOR
 3. PSIKOSIS PARANOID DITANDAI GEJALA
DEPERSONALISASI DAN DEREALISASI ATAU
WAHAM PRIMER,
 4. HALUSINASI KRONIS
Prevalensi
 1% dari populasi dunia (0,85%)
 Insidens 1: 10.000 orang pertahun
 Prevalensi berdasar jenis kelamin,
budaya sama. Wanita gej lebih ringan ,
lebih sedikit rawat inap. Lebih baik
dikomunitas dari pada laki2
 Onset pada laki2 terjadi lebih awal
drpd w
 Onset puncak laki2 umur 15-25 th,
wanita 25 -35 th, jarang pada
usia<10/>50 th.
 Individu yang didiagnosis dengan
skizofrenia 60-70 % tidak pernah
menikah
 25-50% berusaha bunuh diri, 10 %
berhasil
 Faktor resiko kasuk suicide, dejala
depresif, usia muda, tingkat fungsi
pramorbid yang tinggi, halusinasi
dengar, usaha sebelumnya, tinggal
sendiri, perbaikan setelah relaps,
ketergantungan pada rumah sakit,
ambisi yang terlalu tinggi, jenis
kelamin laki2
 Umumnya akan menggunakan zat
untuk menurunkan depresi dan
kecemasannya serta mendapatkna
ETIOLOGI
1.MODEL DIATESIS STRESS
 INTEGRASI ANTARA FAKTOR BIOLOGIS, FAKTOR
PSIKOSOSIAL, LINGKUNGAN, SESEORANG YANG
RENTAN(DIATESIS) JIKA DIKENAI AKAN LEBIH MUDAH
 FAKTOR GENETIKA , 7 GEN MEMPENGARUHI,
KROMOSOM 1,3,5,7,11, DAN KROMOSOM X ,
PENELITIAN GENETIKA INI DIHUBUNGKAN DENGAN
COMT (CATECHOL-O-METHIL TRANSFERASE) DALAM
ENCODING DOPAMIN SEHINGGA MEMPENGARUHI F/
DOPAMIN
 EMOSI TURBULENT FAMILIES, STRESSFUL LIFE
EVENTS, DISKRIMINASI, KEMISKINAN
 DAERAH PERKOTAAN,
 DOWN WARD DRIFT ORANG BERGESER KE KEL
SOSIAL RENDAH ATAU GAGAL KELUAR DARI KEL SOS
RENDAH
 2. FAKTOR NEUROBIOLOGIS
 ASUPAN GIZI KURANG
 TRAUMA PSIKOLOGIS SELAMA MASA HAMIL,
ANAK, KEKERASAN
 PERBEDAAN STRUKTUR, FUNGSI DAERAH OTAK,
PET(POSITRON EMISSION TOMOGRAPHY) DAPAT
TERLIHAT KURANGNYA AKTIVITAS DI DAERAH
LOBUS FRONTAL( MEMORI KERJA, PENURUNAN
AKTIVITAS METABOLIK FRONTAL)
 KADAR PME /FOSFOMONOESTER >RENDAH
 KADAR PDE/FOSFODIESTER YANG >TINGGI
 KADAR FOSFAT INORGANIK MENURUN
 KONSENTRASI ATP MENINGKAT
 SEHINGGA TERJADILAH HIPOFUNGSI DIDAERAH
KORTEKS FRONTAL DORSOLATERAL
 PET, GEJALA NEGATIF= ABNORM METABOLIK > SIRKUIT
FRONTAL, TEMPORAL, SEREBELAR DIBANDINGKAN GEJALA
POSITIF
 MENURUNNYA ATENSI KARENA HIPOAKTIVITAS DI DAERAH
KORTEKS SINGULAT ANTERIOR,
 RETARDASI MOTORIK DENGAN HIPOAKTIF DI DAERAH BASAL
GANGLIA
 HALUSINASI TJD KARENA PERUBAHAN ALIRAN DARAH DI
REGIO HIPOKAMPUS, PARA HIPOKAMPUS, AMIGDALA
 HALUSINASI KRONIK BERHUBUNGAN DENGAN PENINGKATAN
ALIRAN DARAH DI LOBUS TEMPORAL KIRI
 WAHAM TERJADI PENINGKATAN ALIRAN DARAH DI LOBUS
TEMPORAL MEDIAL KIRI DAN PENURUNAN DARAH DI KORTEK
SINGULAT POSTERIOR DAN LOBUS TEMPORAL LATERAL KIRI
 GENGGUAN PENILAIAN REALITA BERHUBUNGAN DENGAN
ALIRAH DARAH DI KORTEKS PREFRONTAL LATERAL KIRI,
STRIATUM VENTRAL , GIRUS TEMPORALIS SUPERIOR, REGIO
HIPOCAMPUS
 DISORGANISASI VERBAL PADA MENURUNNYA AKTIVITAS
DIDAERAH KORTEKS FRONTAL INFERIOR, SINGULAT DAN
TEMPORAL SUPERIOR KIRI
 PENURUNAN F/KOGNITIF DIDAPATI , GANGGUAN
MEMORY (SEGERA, JANGKA PENDEK/MEMORI
KERJA) DAN FUNGSI EKSEKUTIF (KEMAMPUAN
BERBAHASA, MEMECAHKAN MASALAH,
MENGAMBIL KEPUTUSAN, ATENSI,
PERENCANAAN)
 MRI DIDAPAT PELEBARAN DI DAERAH
VENTRIKULAR III DAN LATERAL TERUTAMA BILA
YANG MENONJOL ADALAH GEJALA NEGATIFNYA,
INI IMPLIKASI PERUBAHAN DIDAERAH
VENTRIKULAR LIMBIK STRIATA, MENGECILNYA
UKURAN LOBUS FRONTAL DAN TEMPORAL,
DAERAH OTAK YANG TERLIBAT ADALAH SISTEM
LIMBIK, LOBUS FRONTALIS, GANGLIA BASALIS,
BATANG OTAK DAN TALAMUS
 EEG TERLIHAT HILANGNYA GAMMA BAND 
MELEMAHNYA INTEGRASI ANTARA JARINGAN
SARAF DI OTAK
 TEORI NEUROTRAMSMITER
BERHUBUNGAN DENGAN HIPOTESA
DOPAMIN, SEROTONIN (5HT), GLUTAMAT
DAN NMDA, GABA, NOREPINEFRIN,
PEPTIDA/NEUROTENSIN.
 HIPOTESIS DOPAMIN (D1-D5)
MENGATAKAN BAHWA RESEPTOR D2
SANGAT MEMPENGARUHI SIMPTOM
POSITIF DARI SKIZOFRENIA
TEORI DOPAMIN PATHWAYS
 1. MESOLIMBIK DOPAMIN PATHWAYS
 HIPOTESIS TERJADINYA SIMPTOM POSITIF
 MEMPROYEKSIKAN BADAN SEL DOPAMINERGIK KEBAGIAN
VENTRAL TEGMENTUM AREA (VTA) DI BATANG OTAK KEMUDIAN KE
NUKLEUS AKUMBEN DI DAERAH LIMBIK
 JALUR INI PENTING PADA EMOSIONAL, PRILAKU KHUSUSNYA
HALUSINASI PENDENGARAN, WAHAM, GANGUAN PIKIRAN.
 PSIKOSTIMULAN SEPERTI AMFETAMIN, KOKAIN DAPAT
MENYEBABKAN PENINGKATAN DOPAMIN, PADA JALUR INI, SHG
MENYEBABKAN POSITIF SIMPTOM DAN MENIMBULKAN PSIKOSIS
PARANOID JIKA PEMBERIAN ZAT INI DILAKUKAN SECARA
BERULANG
 ANTIPSIKOTIK BEKERJA MELALUI BLOKADE RESEPTOR DOPAMIN
KHUSUSNYA RESEPTOR DOPAMIN D2 SEHINGGA SIMPTOM POSITIR
DAPT MENURUN ATAU MENGHILANG
 HIPOTESIS HIPERAKTIF MESOLIMBIK DOPAMIN PATHWAY INI
MENYEBABKAN SIMPTOM POSITIF MENINGKAT,  SKIZOFRENIA,
PSIKOSIS YANG DISEBABKAN ZAT, MANIA, DEPRESI /DEMENSIA
 HIPERAKTIF MESOLIMBIK INI PERANAN
AGRESIVITAS, HOSTILITAS PENDERITA
TERUTAMA BILA TERJADI PENYIMPANGAN
KONTROL SEROTONERGIK DARI DOPAMIN
 NUKLEUS AKUMBENS ADALAH BAG SISTEM
LIMBIK YANG PERANAN PADA PRILAKU
SEPERTI PLEASURABLE SENSATION,
POWERFUL EUPHORIA PADA INDIVIDU YANG
MEMILIKI WAHAM, HALUSINASI SERTA PADA
PENGGUNAAN ZAT
 JUGA MEMPUNYAI PERANAN PLEASURE
REWARD, REINFORCING BEHAVIOR, PADA
PENYALAHGUNAAN ZAT MENIMBULKAN
KETERGANTUNGAN KARENA TERJADI
2.MESOKORTIKAL DOPAMIN PATHWAY
 JALUR INI DIMULAI DARI DAERAH
VENTRAL TEGMENTUM AREA KE DAERAH
SEREBRAL KORTEKS KHUSUSNYA
KORTEKS LIMBIK, PERANAN
MESOKORTIKAL DOPAMIN PATHWAY
ADALAM SEBAGI MEDIASI DARI SIMPTOM
NEGATIF DAN KOGNITIF SKIZOFRENIA
 SIMPTOM NEGATIF DAN KOGNITIF
DISEBABKAN TURUNNYA DOPAMIN DI
JALUR MESOKORTIKAL TERUTAMA
DAERAH DORSO LATERAL PREFRONTAL
 DEFISIT BEHAVIORAL YANG DINYATAKAN DALAM
SUATU SIMPTOM NEGATIF BERUPA PENURUNAN
AKTIFITAS MOTORIK, AKTIFITAS YANG
BERLEBIHAN DARI SISTEM GLUTAMAT YANG
BERSIFAT EKSITOTOKSIS PADA SISTEM SARAF
(BURN OUT) YANG KEMUDIAN BERLANJUT
MENJADI SUATU PROSES DEGENERASI DI
MESOKORTIKAL DOPAMIN PATHWAY. INI AKAN
MEMPERBERAT SIMPTOM NEGATIF DAN
MENINGKATKAN DEFISIT YANG TERJADI PADA
SKIZOFREN
 MENINGKATKNA DOPAMIN MEMPERBAIKI
SIMPTOM NEGATIF DAN KOGNITIF
 OBAT ANTIPSIKOTIK GENERASI 2, DAPAT BEKERJA
SECARA SELEKTIF, MENYEBABKAN DOPAMIN DI
MESOLIMBIK MENURUN SEDANGKAN DOPAMIN DI
MESOKORTEK MENINGKAT
3.NIGROSTRIATAL DOPAMIN
PATHWAYS
 BERJALAN DARI SUBSTANSIA NIGRA
PADA BATANG OTAK KE DAERAH
BASAL GANGLIA ATAU STRIATUM
 BAGIAN DARI EKSTRAPIRAMIDAL
BERFUNGSI PENGONTROL GERAKAN
MOTORIK
 PENURUNAN DOPAMIN PD
NIGROSTRIATAL DOPAMIN PATHWAYS
DPT MENYEBABKAN GGG
PERGERAKAN SEPERTI PADA
PARKINSON (RIGIDITAS, AKINESIA,
BRADIKINESIA (PERGERAKAN
BERKURANG / MELAMBAT) DAN
 PENURUNAN DOPAMIN DI DAERAH BASAL
GANGLIA MENYEBABKAN AKATISIA (A TIPE
OF RESTLESSNESS) DAN DISTONIA
(TWISTING MOVEMENT/ PERGERAKAN
KAKU) KHUSUSNYA PADA WAJAH DAN
LEHER
 GGG PERGERAKAN JUGA DAPAT TRJDI
PADA BLOKADE RESEPTOR D2 OLEH PBAT
SEPERTI ANTIPSIKOTIK GENERASI 1
 HIPERAKTIFITAS /PENINGKATAN DOPAMIN
PD NIGROSTRIATAL MENDASARI
TERJADINYA GANGGUAN PERGERAKAN
HIPERKINETIK SEPERTI CHOREA, DISKIESIA
DAN TICS
 TERJADINYA BLOKADE YANG LAMA PADA
RESEPTOR D2 ->TARDIVEDISKINESIA
4.TUBEROINFUNDIBULAR DOPAMIN
PATHWAYS
 DIMULAI DARI HIPOTALAMUS KE HIPOFISIS
ANTERIOR (ANTERIOR PITUITARY)
 DALAM KEADAAN NORMAL
TUBEROINFUDIBULAR DIPENGARUHI OLEH
INHIBISI DAN PELEPASAN PROLAKTIN
 PENURUNAN AKTIFITAS PROLAKTIN SETELAH
MELAHIRKAN BERHUBUNGAN DENGAN
PENINGKATAN PROLAKTIN PADA ASI
 PENINGKATAN PROKLATIN ANTARA LAIN
KARENA TERJADINYA KARENA LESI ATAU
PEMAKAIAN OBAT ANTIPSIKOTIK
 MANIFESTASI KLINIK PENINGKATAN PROLAKTIN
 GALAKTORE (SEKRESI ASI), AMENOREA,
DISFUNGSI SEKSUAL, TERJADI SELAMA ATAY
SETELAH PEMBERIAN OBAT ANTIPSIKOTIK
NEURODEGERATIF DAN
NEUROTOKSISITAS
 ADA 5 HIPOTESIS PERKEMBANGAN NEURON PADA
PENDERITA SKIZOFRENIA
 1. ABNORMARLITAS PERKEMBANGAN OTAK JANIN
SELAMA FASE AWAL DARI SELEKSI NEURON DAN
MIGRASI
 2. TERJADINYA PROSES DEGENERASI ABNORMAL YANG
MUNGKIN BERHUBUNGAN DENGAN GENETIK DALAM
PERKEMBANGAN OTAK JANIN
 3.SIMPTOM DARI INI TIDAK TERJADI SELAMA OTAK
DAPAT MEMPERBAIKI SINAP2 YANG MENGALAMI
GANGGUAN
 4.INFEKSI VIRUS, KURANG GIZI, AUTOIMUN SELAMA
MASA HAMIL MEMPENGARUHI NEURON JANIN SELAMA
DALAM KANDUNGAN DAN DPT MENJADI PERANTARA
TERJADINYA NEKROSIS NEURON DIKEMUDIAN HARI
 5.PERUBAHAN STRUKTUR DAN ABNORMALITAS DARI
NEURON YANG MASIH BERFUNGSI MENGAKIBATKAN
TERJADI INERVASI DARI SINYAL DARI NEURON YANG
HIPOTESIS NEURODEGENERATIF PADA PS
SKIZOFRENIA
 PENURUNAN FUNGSU NEURONAL SECARA PROGRESIF
DAN TERUS MENERUS SLM SKIZO
 PERJALANAN DARI FASE ASIMPTOMATIK PADA USIA
BELASAN TAHUN (FASE 1), BERLANJUT
PRODROMAL(ODDNESS ATAU ANEH) DAN ONSET
SIMPTOM NEGATIF YANG TIDAK KHAS PADA AKHIR USIA
BELASAN KE AWAL USIA 20 AN, (FASE II). FASE AKTIF
DARI SKIZOFRENIA BARU MULAI DAN BERLANJUT
SETELAH USIA 20AN DAN 30 AN DITANDAI DENGAN
SIMPTOM POSITIF , TIDAK PERNAH KEMBALI LAGI PADA
TARAF FUNGSI YANG SEMULA KEMUDIAN DIIKUTI
DENGAN RELAPS AKUT DAN EKSASERBASI AKUT (FASE
III), AKHIRNYA SKIZOFRENIA MENJADI STABIL SETALAH
TERJADI PERBURUKAN FUNGSI NEGATIF DAN KOGNITIF,
YANG MENONJOL DAN PENURUNAN DARI BASELINE
FUNGTIONAL ISTILAH BURN OUT UMUMNYA TERJADI
PADA USIA 40 AN ATAU LEBIH
EKSITOTOKSIS
 GLUTAMAT ASAM AMINO ESENSIAL ,
NEUROTRANSMITER –GLUTAMATERGIK
BERSIFAT EKSITASI DI SSP
 RESEPTOR DARI GLUTAMATERGIK –MENGATUR
MIGRASI DARI NEURON, PERTUMBUHAN
NEURIT, SINAPTOGENESIS, APOPTOSIS
 NEURODEGERATIF PD SKIZOFR DI MEDIASI
MELALUI AKSI DARI NEUROTRANSMITER
GLUTAMAT YANG BERLEBIHAN DAN DIKETAHUI
TERNYATA BERSIFAT EKSITOSIS SHG
MENIMBULKAN KEMATIAN INTRASELULER
NEURON
 NEUROTRANSMITER GLUTAMAT TERDAPAT
DIDAERAH SEREBELUM, HIPOKAMPUS,
 GLUTAMAT DISINTESIS DARIGLUKOSA DAN
GLUTAMIN DIDAERAH TERMINAL PRESINAP DAN
DISIMPAN DALAM VESIKAL SINAP, KEMUDIAN
GLUTAMAT AKAN DILEPASKAN DARI VESIKEL KE
CELAH SINAP, NEUROTRANSMITER INI AKAN
BEKERJA PADA RESEPTOR DAN AKTIVITASNYA
DIBATASI OLEH MEKANISME REUPTAKE
 GLUTAMIN MERUPAKAN PREKURSOR YANG
PENTING DARI GLUTAMAT, NIKOTIN AKAN
MENSTIMULASI PELEPASAN GLUTAMAT KE CELAH
SINAP
 JADI HIPOTESIS EKSITOTOKSIS PADA SKIZOFREN
KAREAN DEGENERASI NEURON DISEBABKAN
EXCESSIVE EKSITATORY NEUROTRANSMITTER
GLUTAMATE SHG MENIMBULKAN SUATU
APNORMAL RESIPROCAL GLUTAMATERGIZ
CORTOCO THALAMIC CIRCUIT
RESEPTOR GLUTAMAT ADA 5
 1. NMDA (N-METHYL-D-ASPARTANTE)
 2. AMPA (ALPHA AMINO 3 HYDROXY 5 METHYL 4
ISOXAZOLE PROPIONIC ACID
 3. KAINATE
 4.L-AP4 (L-2-AMINO-4-PHOSPHONOBUTYRATE)
 5. ACPD (TRANS-1-AMINOCYCLOPENTANE-1,3
DICARBOXYLIC ACID)
 RESEPTOR NMDA,AMPA, KAINATE BERHUBUNGAN
DENGAN ION CHANEL, RESEPTOR INI DISEBUT
RESEPTOR IANOTTROPIK KARENA MEMPUNYAI
KANAL SPECIFIK UNTUK KATION (NA,K,CA) SHG
TJD AKTIVASI CEPAT DAN DALAM WAKTU CEPAT
 RESEPTOR METABOTROPIK ADALAH RESEPTOR
YANG BERFUNGSI MENGAKTIFKAN SECOND
MESSENGER SPT CYCLIC ADENOSINE
MONOPHOSPHATE (CMAP) TETAPO DALAM HAL
INI BUTUH WAKTU LAMA
 EKSITOSIS MEMEDIASI TERJADINYA
GANGGUAN NEUROLOGIK DAN GANGGUAN
PSIKIATRI MLL NEUROGENESIS, MEKANISME
EKSITOSIS MENYEBABKAN PATOLOGI DI
DAERAH SINAP
 GLUTAMAT JUGA PERANAN PATOFIFIOLOGI
SKIZOFRENIA TERUTAMA SIMPTOM POSITIF
DAN NEGATIF
 OBAT ANTIPSIKOTIK MEMPNGARUHI
NEUROTRANSMITER GLUTAMAT DENGAN
MENINGKATKAN PELEPASANNYA, INTERAKSI
DENGAN RESEPTOR GLUTAMAT ATAU
DENGAN MEMPENGARUHI DENSITAS
MAUPUN KOMPOSISI SUB UNIT DARI
RESEPTOR GLUTAMAT
 NEUROGENETIK PADA SKIZOFREN DPT
KARENA: ANOKSIA JANIN, TOKSIN SELAMA
HAMIL, KURANG GIZI SLM HAMIL, INFEKSI
JANIN, DESTRUKSI PROGRAM GENETIK
DIAGNOSIS SKIZOFRENIA MENURUT
DSM IV-TR
A.TERDAPAT 2 ATAU LEBIH GEJALA
DIBAWAH INI SELAMA 1 BULAN ATAU
KURANG DARI SEBULAN JIKA
PENGOBATAN BERHASIL
 1. WAHAM.
 2. HALUSINASI.
 3. BICARA DISORGANISASI.
 4. PERILAKU DISORGANISASI/KATATONIK
YANG JELAS.
 5. SIMPTOM NEGATIF (AFEK DATAR,
ALOGIA, AVOLITION

 NOTE = DAPAT HANYA 1 GEJL BILA DIJUMPAI WAHAM


 B. DISFUNGSI SOSIAL /PEKERJAAN
 C. DURASI GANGGUAN TERUS
MENERUS SELAMA 6 BULAN
 D.DISINGKIRKAN GANGGUAN
SKIZOAFEKTIF DAN GANGGUAN MOOD
 E. DISINGKIRKAN GANGGUAN
PENGGUNAAN ZAT ATAU KONDISI
MEDIS UMUM
 F.JIKA TERDAPAT GANGGUAN
PERKEMBANGAN PERVASIF, DIAGNOSIS
TAMBAHAN SKIZOFRENIA DIBUAT BILA
WAHAM DAN HALUSINASI MENONJOL
SUBTIPE SKIZOFRENIA DSM IV
TR
1.TIPE KATATONIK
 TERDAPAT 2/> GEJALA BERIKUT INI
 1. IMMOBILITAS MOTORIK BERUPA
KATALEPSI, WAXY FLEKSIBILITAS/STUPOR
 2. AKTIVITAS MOTORIK YANG
BERLEBIHAN, TETAPI TIDAK MEMILIKI
TUJUAN DAN TIDAK DIPENGARUHI OLEH
STIMULI EKSTERNAL
 3. NEGATIVISME YANG EKSTRIM, MUTISME
 4. GERAKAN VOLUNTER YANG ANEH,
DITUNJUKAN OLEH POSTURING, GERAKAN
STEREOTIPIK, MANERISME, ATAU
GRIMACING (SERINGAI) YANG MENONJOL
2. TYPE DISORGANISASI (HEBEFRENIK)
 SEMUA KRITERIA DIBAWAH INI
TERPENUHI
A. MENONJOLNYA DISORGANISASI BICARA
DAN PERILAKU, AFEK DATAR/AFEK TIDAK
SESUAI
B. KRITERIA SKIZOFRE KATATONIK TDK
TERPENUHI
3. TYPE PARANOID
SEMUA KRITERIA INI TERPENUHI YAITU:
G. PREOKUPASI DGN WAHAM/HALUSINASI
DENGAR YANG MENONJOL
H. KRITERIA SKIZOFRENIA TIPE
DIORGANISASI TIDAK TERPENUHI
4. TYPE TIDAK TERGOLONGKAN
(UNDIFERENTIATED TYPE) TIDAK
MEMENUHI KRITERIA UNTUK TIPE
PARANOID, DISORGANISASI /KATATONIK
 5. TYPE RESIDUAL
 A. TIDAK TERDAPAT WAHAM,
HALUSINASI, DISORGANISASI BICARA,
PERILAKU
KATATONIK/DISORGANISASI
PERILAKU YG MENONJOL
 B. TERDAPAT TERUS MENERUS
GANGGUAN SPT DITUNJUKNA OLEH
ADANYA GEJALA NEGATIF/ 2 /LEBIH
GEJALA DARI KRITERIA A MENURUT
DSM IV TR DARI SKIZOFRENIA DALAM
BENTUK LEBIH RINGAN *KEYAKINANA
YANG ANEH, PENGALAMAN PERSEPSI
6. SKIZOFRENIA SIMPLEKS
(GANGGUAN DETERIORATIF
SEDERHANA)
KRITERI DIAGNOSTIK DSM IV TR
 A.PERKEMBANGAN YANG BERSIFAT
PROGRESIF DAN SUDAH BERLANGSUNG
MINIMAL 1 TAHUN, DAPAT BERUPA:
1. PENURUNAN YG NYATA DALAM F/
PEKERJAAN/AKADEMIK
2. PENAMPAKAN DAN PENDALAMAN
SECARA BERTAHAP DARI SIMPTOM
NEGATIF
3. RAPPORT INTERPERSONAL YANG
BURUK, ISOLASI SOSIAL ATAU PENARIKAN
KRITERIA MENURUT PPDGJ
III
APABILA ADA 1/ > GEJALA YANG AMAT JELAS
BIASANYA 2/> GEJALA KURANG
JELAS/KURANG TAJAM) DARI GEJALA
DIBAWAH INI
 A. THOUGHT ECHO, THOUGHT INSERTION/
WITHDRAWAL/ THOUGHT BROADCASTING
 B. DELUSION OF CONTROL, DELUSION OF
INFLUENCE/ DELUSION OF PASSIVITY
 C. HALUSINASI SUARA BERUPA KOMENTAR
TERUS MENERUS/MENDISKUSIKAN
TENTANG PS
 2.MINIMAL TERDAPAT 2 GEJALA DARI
GEJALA2 DIBAWAH INI APABILA SEMUA
GEJALA DIATAS TIDAK DITEMUKAN
E. HALUSINASI YANG MENETAP
F. ARUS PIKIRAN YANG TERPUTUS ATAU
MENGALAMI SISIPAN SEHINGGA
INKOHEREN/ PEMBICARAANNYA TIDAK
RELEVAN
G. PERILAKU KATATONIK
H. GEJALA NEGATIF
GEJALA A,B,C,D,E,F,G,H KHAS DAN
BERLANGSUNG 1 BULAN/> KRITERUA INI
TIDAK DAPAT DIGUNAKAN BILA
PENDERITA MASIH FASE PRODROMAL
 4.
SKIZOFRENIA TDK DAPAT
DITEGAKKAN BILA TERDAPAT:
GEJALA DEPRESIF/MANIK SCR
LUAS, PENYAKIT OTAK
NYATA/EPILEPSI (LAIN)
INTOKSIKASI, WITHDRAWAL ZAT
 5. APABILA GEJALA SKIZOFRENIA
DAN GEJ AFEKTIF BERKEMBANG
BERSAMA-SAMA SECARA
SEIMBANG DAN SAMA BANYAK
MAKA GANGUAN TERSEBUT
DIKENAL GANGGUAN
SKIZOAFEKTIF
TYPE SKIZOFRENIA MENURUT PPDGJ III
 1. TYPE PARANOID (F20.0)
 A. MERUPAKAN TYPE YANG PALING
SERING DITEMUKAN
 B. GAMBARAN KLINIS DIDOMINASI OLEH
WAHAM YANG BERSIFAT STABIL,
BIASANYA DISERTAI OLEH HALUSINASI
DAN GANGGUAN PERSEPSI
 C. KRITERIA DIAGNOSTIK
- HALUSINASI/WAHAM HARUS MENONJOL
- GANGGUAN AFEKTIF, DORONGAN
KEHENDAK DAN PEMBICARAAN SERTA
GEJALA KATATONIK YANG TIDAK NYATA
 - HALUSINASI PENDENGARAN DPT
BERUPA ANCAMAN, PERINTAH KPD
PASIEN ATAU HALUSINASI TANPA
BENTUK VERBAL SEPERTI BUNYI
PLUIT, BERDENGUNG, TAWA.
HALUSINASI PENCIUMAN ATAU
PENGECAPAN RASA/BERSIFAT
SEXUAL
- WAHAM YANG BERUPA
DIKENDALIKAN, DIPENGARUHI,
PASSIVITY / KEJAR. PALING KHAS
WAHAM KEJAR
 2. TIPE HEBEFRENIK (F20-1)
 - MENEGAKKAN DIAGNOSIS
SKIZOFRENIA TIPE HEBEFRENIK INI
PERLU DILAKUKAN OBSERVASI SELAMA
2-3 BULAN UNTUK MELIHAT APAAH
GEJALA TERSEBUT BERTAHAN ATAU
TIDAK
 - TERDAPAT GANGGUAN AFEKTIF,
DORONGAN KEHENDAK DAN GANGGUAN
PROSES PIKIR YANG MENONJOL
 CIRI KHAS TYPE INI ADALAH ADANYA
PERILAKU TANPA TUJUAN DAN TANPA
TIPE KATATONIK (F20.2)
 1. SKIZOFRENIA TIPE INI JARANG
DITEMUKAN
 2. KRITERIA DIAGNOSTIK
- TERPENUHI KRITERIA SKIZOFRENIA
- TERDAPAT 1/ > GEJALA2 SPT:
STUPOR/MUTISME, KEGELISAHAN,
POSTURING, NEGATIVISME, RIGIDITAS,
WAXY FLEXIBILITAS / COMMAND
OUTOMATISME
3. APABILA PASIEN TIDAK KOMUNIKATIF
DAN TERDAPAT MANIFESTASI PERILAKU
KATATONIK MAKA UNTUK SEMENTARA
PENEGAKAN DIAGNOSIS HARUS
DITUNDA SAMPAI ADA BUKTI
4. TIPE TAK TERINCI
(UNDIFFERENTIATED) F20.3
 KRITERIA SKIZOFRENIA TERPENUHI TAPI TIDAK
MEMENUHI TYPE YANG LAIN
 5. TYPE RESIDUAL
TYPE INI MERUPAKAN STADIUM KRONIS
KRITERIA DIAGNOSTIK
- GEJALA NEGATIF MENONJOL
- ADA RIWAYAT SATU EPISODE PSIKOTIK YANG
JELAS DIMASA LALU YANG MEMENUHI KRITERIA
SKIZOFREN
- PALING SEDIKIT MELAMPAUI KURUN WAKTU 1
TAHUNM INTENSITAS DAN FREKUENSI GEJALA
YANG NYATA SANGAT BERKURANG DAN TELAH
MENIMBULKAN SINDROM NEGATIF
- TIDAK TERDAPAT DIMENSIA, PENYAKIT OTAK
ORGANIK, ATAU DEPRESI KRONIS
TIPE SIMPLEKS (F20.6)
 A. SIMPTOM NEGATIF BERSIFAT
BERLAHAN2 TAPI PROGRESIF
 B. TDK TERDAPAT WAHAM DAN
HALUSINASI
 C. KURANG NYATA GEJALA PSIKOTIK JUKA
DIBANDINGKAN DENGAN SKIZOFRENIA
TIPE LAIN
 D.SIMPTOM NEGATIF TIMBUL TANPA
DIDAHULUI OLEH GEJALA2 PSIKOTIK
YANG NYATA
TIPE DEPRESI PASCE SKIZOFRENIA
(F.20.4)
 A. SKIZOFRENIA SUDAH
BERLANGSUNG 1 TAHUN
 B. GEJALA SKIZOFRENIA MASIH
TETAP ADA
 C. TERDAPAT GEJALA2 DEPRESIF
YANG MENONJOL DAN
MENGGANGGU, MEMENUHI EPISODE
DEPRESIF DAN BERLANGSUNG MIN 2
MINGGU
POLA PERJALANAN SKIZOFRENIA MENURUT
PPDGJ III DENGAN KODE 5 KARAKTER
 F20.X.

O. BERKELANJUTAN
1. EPISODIK DGN KEMUNDURAN
PROGRESIF
2. EPISODIK DGN KEMUNDURAN
STABIL
 3. EPISODIK BERULANG
 4. REMISI TIDAK SEMPURNA
 5. REMISI SEMPURNA
 8. LAINNYA
 9. PERIODE PENGAMATAN KURANG
1 TH
POLA PERJALANAN SKIZOFRENIA
MENURUT DSM IV TR
 1. EPISODIK DGN SIMPTOM RESIDUAL
ANTARA EPISODE
 2. EPISODIK TANPA SIMPTOM RESIDUAL
ANTARA EPISODE
 3. BERKELANJUTAN
 4. EPISODIK TUNGGAL DENGAN REMISI
SEBAGIAN
 5. EPISODIK TUNGGAL DENGAN REMISI
PENUH
 6. POLA TIDAK SPESIFIK ATAU LAINNYA
PROGNOSIS SKIZOFRENIA
 CIRI-CIRI PROGNOSIS BAIK
 LATE ONSET
 ONSET AKUT
 MEMPUNYAI FAKTOR PENCETUS YANG
JELAS
 MEMILIKI RIWAYAT PRAMORBID YANG
BAIK DALAM SOSIAL, SEKSUAL, DAN
PEKERJAAN
 DIJUMPAI SIMPTOM DEPRESI
 TELAH MENIKAH
 MEMILIKI RIWAYAT KELUARGA DENGAN
GANGUAN MOOD
 MEMPUNYAI SISTEM SUPPORT YANG BAIK
PROGNOSIS BURUK
 ONSET USIA MUDA
 ONSET PERLAHAN-LAHAN DAN TIDAK JELAS
 TIDAK ADA FAKTOR PENCETUS
 MEMILIKI RIWAYAT PRAMORBID JELEK
 DIJUMPAI PERILAKU MENARIK DIRI ATAUR AUTISTIK
 BELUM MENIKAH/CERAI
 MEMILIKI RIWAYAT KELUARGA SKIZOFRENIA
 MEMILIKI SISTEM SUPPORT BURUK
 GAMBARAN KLINIS ADALAM SIMPTON
NEGATIF/SIMPTON NEUROLOGI
 MEMILIKI RIWAYAT TRAUMA MASA PERINATAL
 TIDA ADA REMISI SELAMA 3 TAHUN PENGOBATAN
 TERJADINYA BANYAK RELAPS
 MEMILIKI RIWAYAT SKIZOFRENIA SEBELUMNYA
Schizophrenia
KAPLAN & SADOCK

EDIT DR LIZA
Schizophrenia
 Schizophrenia is a clinical syndrome of variable, but
profoundly disruptive, psychopathology that involves
cognition, emotion, perception, and other aspects of
behavior. The expression of these manifestations
varies across patients and over time, but the effect
of the illness is always severe and is usually long
lasting.
 The disorder usually begins before age 25, persists
throughout life, and affects persons of all social
classes. Both patients and their families often suffer
from poor care and social ostracism because of
widespread ignorance about the disorder. Although
schizophrenia is discussed as if it is a single disease,
it probably comprises a group of disorders with
heterogeneous etiologies, and it includes patients
whose clinical presentations, treatment response,
and courses of illness vary.
 Clinicians should appreciate that the diagnosis of
 Kurt Schneider Criteria for Schizophrenia
 First-rank symptoms
– Audible thoughts
– Voices arguing or discussing or both
– Voices commenting
– Somatic passivity experiences
– Thought withdrawal and other experiences of influenced
thought
– Thought broadcasting
– Delusional perceptions
– All other experiences involving volition made affects,
and made impulses
 Second-rank symptoms
– Other disorders of perception
– Sudden delusional ideas
– Perplexity
– Depressive and euphoric mood changes
– Feelings of emotional impoverishment
– “…and several others as well”
 DSM-IV-TR Diagnostic Criteria for Schizophrenia
 A.Characteristic symptoms: Two (or more) of the
following, each present for a significant portion of time
during a 1-month period (or less if successfully treated):
– delusions
– hallucinations
– disorganized speech (e.g., frequent derailment or
incoherence)
– grossly disorganized or catatonic behavior
– negative symptoms, i.e., 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 the person's
behavior or thoughts, or two or more voices conversing
with each other.
 B.Social/occupational dysfunction: For a significant
portion of the time since the onset of the disturbance,
one or more major areas of functioning such as work,
interpersonal relations, or self-care are markedly below
the level achieved prior to the onset (or when the onset
 C. Duration: Continuous signs of the disturbance
persist for at least 6 months. This 6-month period
must include at least 1 month of symptoms (or
less if successfully treated) that meet Criterion A
(i.e., active-phase symptoms) and may include
periods of prodromal or residual symptoms.
During these prodromal or residual periods, the
signs of the disturbance may be manifested by
only negative symptoms or two or more
symptoms listed in Criterion A present in an
attenuated form (e.g., odd beliefs, unusual
perceptual experiences).
 D. Schizoaffective and mood disorder exclusion:
Schizoaffective disorder and mood disorder with
psychotic features have been ruled out because
either (1) no major depressive, manic, or mixed
episodes have occurred concurrently with the
active-phase symptoms; or (2) if mood episodes
have occurred during active-phase symptoms,
their total duration has been brief relative to the
duration of the active and residual periods.
 E. Substance/general medical condition
exclusion: The disturbance is not due to
the direct physiological effects of a
substance (e.g., a drug of abuse, a
medication) or a general medical
condition.
 F. Relationship to a pervasive
developmental disorder: If there is a
history of autistic disorder or another
pervasive developmental disorder, the
additional diagnosis of schizophrenia is
made only if prominent delusions or
hallucinations are also present for at least
a month (or less if successfully treated).
 Classification of longitudinal course (can be applied
only after at least 1 year has elapsed since the initial
onset of active-phase symptoms):
   Episodic with interepisode residual symptoms
(episodes are defined by the reemergence of
prominent psychotic symptoms); also specify if: with
prominent negative symptoms Episodic with no
interepisode residual symptoms
   Continuous (prominent psychotic symptoms are
present throughout the period of observation); also
specify if: with prominent negative symptoms
   Single episode in partial remission: also specify
if: with prominent negative symptoms
   Single episode in full remission
   Other or unspecified pattern(From American
Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders. 4th ed. Text rev.
Washington, DC: American Psychiatric Association;
copyright 2000, with permission.)
DSM-IV-TR Diagnostic Criteria for
Schizophrenia
 Sub types
Paranoid type
A type of schizophrenia in which the following criteria
are met:
 Preoccupation with one or more delusions or frequent
auditory hallucinations.
 None of the following is prominent: disorganized
speech, disorganized or catatonic behavior, or flat or
inappropriate affect.
Disorganized type
A type of schizophrenia in which the following criteria
are met:
 All of the following are prominent:
– disorganized speech
– disorganized behavior
– flat or inappropriate affect
 The criteria are not met for catatonic type.
 Catatonic type
 A type of schizophrenia in which the clinical
picture is dominated by at least two of the
following:
 motoric immobility as evidenced by catalepsy
(including waxy flexibility) or stupor
 excessive motor activity (that is apparently
purposeless and not influenced by external
stimuli)
 extreme negativism (an apparently motiveless
resistance to all instructions or maintenance of
a rigid posture against attempts to be moved)
or mutism
 peculiarities of voluntary movement as
evidenced by posturing (voluntary assumption
Undifferentiated type
A type of schizophrenia in which symptoms that meet
Criterion A are present, but the criteria are not met for
the paranoid, disorganized, or catatonic type.

Residual type

A type of schizophrenia in which the following criteria are


met:
 Absence of prominent delusions, hallucinations,
disorganized speech, and grossly disorganized or
catatonic behavior.
 There is continuing evidence of the disturbance, as
indicated by the presence of negative symptoms or two
or more symptoms listed in Criterion A for
schizophrenia, present in an attenuated form (e.g., odd
beliefs, unusual perceptual experiences).
TYPE PARANOID
 The following case illustrates ideas of reference and
paranoid delusions. A married man, age 38, with a
history of dependable, conscientious work as a
bookkeeper, became sleepless, anxious, and unable
to concentrate. He developed the belief that his
vision was failing because of poisons secretly placed
in his food by former neighbors. He found a misprint
in a newspaper that he felt was placed there by the
editor to shame him publicly. Admitted to the
psychiatric service of a general hospital, he said that
cars passing up and down the street contained
agents who were spying on him. He believed that the
electric light bulbs in his room were emanating a
purifying radiation to counteract syphilitic germs,
which he was supposedly breathing into the
atmosphere, although a physical examination was
negative for syphilis.
 Disorganized Type
 The disorganized (formerly called hebephrenic)
type of schizophrenia is characterized by a
marked regression to primitive, disinhibited, and
unorganized behavior and by the absence of
symptoms that meet the criteria for the catatonic
type. The onset of this subtype is generally early,
occurring before age 25. Disorganized patients
are usually active but in an aimless,
nonconstructive manner. Their thought disorder is
pronounced, and their contact with reality is poor.
Their personal appearance is disheveled, and
their social behavior and their emotional
responses are inappropriate. They often burst into
laughter without any apparent reason.
Incongruous grinning and grimacing are common
in these patients, whose behavior is best
described as silly or fatuous.
Disorganized Type
 Patient AB, a 32-year-old woman, began to lose
weight and became careless about her work, which
deteriorated in quality and quantity. She believed that
other women at her place of employment were
circulating slanderous stories concerning her and
complained that a young man employed in the same
plant had put his arm around her and insulted her.
Her family demanded that the charge be investigated,
which showed not only that the charge was without
foundation but also that the man in question had not
spoken to her for months. One day she returned home
from work, and as she entered the house, she laughed
loudly, watched her sister-in-law suspiciously, refused
to answer questions, and at the sight of her brother
began to cry. She refused to go to the bathroom,
saying that a man was looking in the windows at her.
She ate no food, and the next day declared that her
sisters were bad women, that everyone was talking
about her, and that someone had been having sexual
relations with her, and although she could not see
 The patient was admitted to a public psychiatric hospital.
As she entered the admitting office, she laughed loudly
and repeatedly screamed in a loud tone, She cannot stay
here; she's got to go home She grimaced and performed
various stereotyped movements of her hands. When seen
on the ward an hour later, she paid no attention to
questions, although she talked to herself in a childish tone.
She moved about constantly, walked on her toes in a
dancing manner, pointed aimlessly about, and put out her
tongue and sucked her lips in the manner of an infant. At
times she moaned and cried like a child but shed no tears.
As the months passed, she remained silly, childish,
preoccupied, inaccessible, grimacing, gesturing, pointing
at objects in a stereotyped way, and usually chattering to
herself in a peculiar high-pitched voice, with little of what
she said being understood. Her condition continued to
deteriorate, she remained unkempt, and she presented a
picture of extreme introversion and regression, with no
interest either in the activities of the institution or in her
relatives who visited her. (Adapted from case of Arthur P.
Noyes, M.D., and Lawrence C. Kolb, M.D.)
Catatonic Type
 AC, age 32, was admitted to the hospital.
On arrival, he was noted to be an
asthenic, poorly nourished man with
dilated pupils, hyperactive tendon
reflexes, and a pulse rate of 120. He
showed many mannerisms, laid down on
the floor, pulled at his foot, made
undirected violent striking movements,
struck attendants, grimaced, assumed
rigid and strange postures, refused to
speak, and appeared to be having
auditory hallucinations. When seen later
in the day, he was found to be in a
stuporous state. His face was without
expression, he was mute and rigid, and he
paid no attention to those about him or to
their questions. His eyes were closed, and
 He gradually became accessible, and when
asked concerning himself, he referred to
his stuporous period as sleep and
maintained that he had no recollection of
any events occurring during it. He said,
didn't know anything. Everything seemed
to be dark as far as my mind is concerned.
Then I began to see a little light, like the
shape of a star. Then my head got through
the star gradually. I saw more and more
light until I saw everything in a perfect
form a few days ago. He explained his
mutism by saying that he had been afraid
he would say the wrong thing and also that
he didn't know exactly what to talk about.
From his obviously inadequate emotional
response and his statement that he was a
scientist and an inventor of the most
extraordinary genius of the twentieth
century, it was plain that he was still far
Undifferentiated Type
 Frequently, patients who are clearly schizophrenic cannot be easily
fit into one type or another. DSM-IV-TR classifies these patients as
having schizophrenia of the undifferentiated type.

 A 15-year-old girl attended a summer camp, where she had


difficulties getting along with the other children and developed
animosity toward one of the counselors. On her return home, she
refused to listen to her parents and said she heard the voice of a
man talking to her, although she could not see him. She rapidly
began to show bizarre behavior, characterized by grimacing,
violent outbursts, and inability to take care of herself.
 Her school record has always been good, and she was fluent in
three languages. Her parents described her as having been a
quiet, rather shut-in child with no abnormal traits in childhood.
Family relations were reported as having been satisfactory.
 On admission to a psychiatric hospital, the patient's speech was
incoherent. She showed marked disturbances of formal thinking
and blocking of thoughts. She was impulsive and appeared to be
hallucinating. She stated that she heard voices in her right ear that
a popular singer was running after her with a knife. She also
thought that her father was intent on killing her. She thought that
 She was often incontinent, and most of the
time neglected her physical appearance. But
occasionally she spent hours dressing herself,
looking in the mirror, and putting on
excessive makeup. At times, she was eating
her feces. Occasionally, she adopted the roles
of a singer or dancer. She made incoherent
statements like: Will I live forever? Nurse, I
don't throw may love away. It is my stomach
and it hurts. In the dining room, she
attempted to grasp the genitals of male
patients.
 Two months of neuroleptic treatment brought
no apparent improvement. She was given a
course of electroconvulsive therapy (ECT).
She remained in the hospital, where her
behavior continued to be very distrubed.
Residual Type
 According to DSM-IV-TR, the residual type of
schizophrenia is characterized by continuing
evidence of the schizophrenic disturbance in the
absence of a complete set of active symptoms or
of sufficient symptoms to meet the diagnosis of
another type of schizophrenia. Emotional
blunting, social withdrawal, eccentric behavior,
illogical thinking, and mild loosening of
associations commonly appear in the residual
type. When delusions or hallucinations occur,
they are neither prominent nor accompanied by
strong affect (Fig. 13-7).
Other Subtypes
 The subtyping of schizophrenia has had a long
history; other subtyping schemes appear in the
literature, especially literature from countries
other than the United States.
 Paraphrenia
 The term paraphrenia is sometimes
used as a synonym for paranoid
schizophrenia, or for either a
progressively deteriorating course of
illness or the presence of a well-
systemized delusional system. The
multiple meanings of the term render
it ineffectual in communicating
information.
 Pseudoneurotic Schizophrenia
 Occasionally, patients who initially have
such symptoms as anxiety, phobias,
obsessions, and compulsions later reveal
symptoms of thought disorder and
psychosis. These patients are
characterized by symptoms of pananxiety,
panphobia, panambivalence, and
sometimes chaotic sexuality. Unlike
persons with anxiety disorders,
pseudoneurotic patients have free-floating
anxiety that rarely subsides. In clinical
descriptions, the patients seldom become
overtly and severely psychotic. This
condition is currently diagnosed in DSM-IV-
TR as borderline personality disorder.
Simple Deteriorative
Disorder
 Simple Deteriorative Disorder (Simple
Schizophrenia)
 Simple deteriorative disorder is characterized by
a gradual, insidious loss of drive and ambition.
Patients with the disorder are usually not overtly
psychotic and do not experience persistent
hallucinations or delusions. Their primary
symptom is withdrawal from social and work-
related situations. The syndrome must be
differentiated from depression, a phobia, a
dementia, or an exacerbation of personality
traits. Clinicians should be sure that patients truly
meet the diagnostic criteria for schizophrenia
before making the diagnosis. Simple deteriorative
disorder appears as a diagnostic category in an
Simple Deteriorative Disorder (Simple
Schizophrenia)
 An unmarried man, 27 years old, was brought to the mental
hospital because he had on several occasions become
violent toward his father. For a few weeks, he had
hallucinations and heard voices. The voices eventually
ceased, but he then adopted a strange way of life. He would
sit up all night, sleep all day, and become very angry when
his father tried to get him out of bed. He did not shave or
wash for weeks, smoked continuously, ate very irregularly,
and drank enormous quantities of tea.
 In the hospital, he adjusted rapidly to the new environment
and was found to be generally cooperative. He showed no
marked abnormalities of mental state or behavior, except
for his lack of concern for just about anything. He kept to
himself as much as possible and conversed little with
patients or staff. His personal hygiene had to be supervised
by the nursing staff; otherwise, he would quickly become
dirty and untidy.
 Six years after his admission to the hospital, he is described
as shiftless and careless, sullen and unreasonable. He lies
on a couch all day long. Although many efforts have been
made to get the patient to accept therapeutic work
assignments, he refuses to consider any kind of regular
occupation. In the summer, he wanders about the hospital
grounds or lies under a tree. In the winter, he wanders
 DSM-IV-TR Research Criteria for Simple
Deteriorative Disorder (Simple
Schizophrenia)
 Progressive development over a period of at
least a year of all of the following:
– marked decline in occupational or academic
functioning
– gradual appearance and deepening of negative
symptoms such as affective flattening, alogia, and
avolition
– poor interpersonal rapport, social isolation, or social
withdrawal
 Criterion A for schizophrenia has never been
met.
 The symptoms are not better accounted for by
schizotypal or schizoid personality disorder, a
 Suicide
 Suicide is the single leading cause of premature death
among people with schizophrenia. Suicide attempts are
made by 20 to 50 percent of the patients, with long-
term rates of suicide estimated to be 10 to 13 percent.
These numbers reflect an approximately 20-fold
increase over the suicide rate in the general population.
Often, suicide in schizophrenia seems to occur “out
of the blue, without prior warnings or expressions of
verbal intent. The most important factor is the presence
of a major depressive episode. Epidemiological studies
indicate that up to 80 percent of schizophrenia patients
may have a major depressive episode at some time in
their lives. Some data suggest that those patients with
the best prognosis (few negative symptoms,
preservation of capacity to experience affects, better
abstract thinking) can paradoxically also be at highest
risk for suicide. The profile of the patient at greatest
risk is a young man
 who once had high expectations, declined
from a higher level of functioning, realizes
that his dreams are not likely to come true,
and has lost faith in the effectiveness of
treatment. Other possible contributors to the
high rate of suicide include command
hallucinations and drug abuse.
 Two-thirds or more of schizophrenic patients
who commit suicide have seen an apparently
unsuspecting clinician within 72 hours of
death. A large pharmacological study
suggests that clozapine (Clozaril) may have
particular efficacy in reducing suicidal
ideation in schizophrenia patients with prior
hospitalizations for suicidality. Adjunctive
antidepressant medications have been
shown to be effective in alleviating co-
occurring major depression in schizophrenia.
 The following is an example of an unpredictable
suicide in a schizophrenic who had been
responding to psychiatric treatment:
 The patient had been an autistic child and did
not speak until he was 7 years old. He had
responded well to psychiatric treatment, and at
age 13 his IQ was reported as 122. At age 17 he
became violent toward his parents, shaved all
his hair off, and made such statements as, I like
bank robbers knocking people unconsciousand I
think tough gangs are funny because they beat
down people. While saying this, he laughed
loudly. He was admitted to a mental hospital,
where he responded with definite improvement
to pharmacotherapy and psychotherapy, and
he went home regularly for weekends.
 He left various notes on his desk before
committing suicide. Among these notes was an
eight-page list giving 211 excusable mistakes
throughout my life. Each one was dated, for
example, 1952, 2nd of November: throwing up in
my friend's house on a shoe-box. 1953, 17th
August: accidentally wearing a watch that wasn't
water-proof in the bath-tub. 1956, 23rd of
September: slamming back-door of Meteor after
getting in.
 He then proceeded in his notes to give the causes
of the mistakes:Montreal having a mountain; I
have a receding hair-line; my height since I was
nine years old; Canada having two languages He
also wrote: My feelings of tension since 1962 is
getting worse most of the time. I planned the
date of my death without the slightest trace of
emotion
 The boy hanged himself at age 18 in the family
garage. An experienced psychiatrist who had
repeatedly interviewed him noted no signs of
Homicide

 Homicide
 Despite the sensational attention that the news
media provides when a patient with
schizophrenia murders someone, the available
data indicate that these patients are no more
likely to commit homicide than is a member of
the general population. When a patient with
schizophrenia does commit homicide, it may be
for unpredictable or bizarre reasons based on
hallucinations or delusions. Possible predictors
of homicidal activity are a history of previous
violence, dangerous behavior while
hospitalized, and hallucinations or delusions
A schizophrenic man who had been going
home on weekends for many months was
told by his sister that she would not ask
for permission any more to take him out
of the hospital if he would not do his part
with the housework in the future, for
instance, help with the dishes. On the
next weekend visit, the patient killed his
sister and mother. He had shown no signs
of disturbance whatsoever during the
preceding week, had been sleeping well,
and had been attending occupational
therapy classes as usual.
 A 19-year-old boy who had been
discharged from a mental hospital, in what
appeared to be a residual state of chronic
schizophrenia of the undifferentiated type,
stabbed his father to death when the
latter, during a state of intoxication, told
the patient that he was too much of a
bother around the house and that he
might as well return to the hospital.
 Another schizophrenic, whose condition
had not yet been diagnosed, complained
to a general practitioner about various
physical ailments. When the physician
finally told him that he should not come
anymore because there was nothing else
he could do for him, the patient quickly
 DSM-IV-TR Diagnostic Criteria for
Schizophreniform Disorder
 Criteria A, D, and E of schizophrenia are met.
 An episode of the disorder (including prodromal,
active, and residual phases) lasts at least 1 month
but less than 6 months. (When the diagnosis must be
made without waiting for recovery, it should be
qualified as “provisional.”)
 Specify if:
   Without good prognostic features With good
prognostic features: as evidenced by two (or
more) of the following:
 onset of prominent psychotic symptoms within 4
weeks of the first noticeable change in usual
behavior or functioning
 confusion or perplexity at the height of the psychotic
episode
 good premorbid social and occupational functioning
 absence of blunted or flat affect
 Ms. V was a 30-year-old white woman from a working-class family.
She was born prematurely and as a toddler had a seizure disorder
that was treated with phenobarbital (Luminal, Solfoton) for 1 year.
She did well in school, but dropped out in the 12th grade, obtained a
General Educational Development (GED) diploma, and began
working at 18 years of age.
 She described her adolescence as a time when she was happy,
outgoing, and had several friends. She married at 21 years of age
and had two children, but 9 months before her initial hospitalization,
she and her husband separated.
 Ms. V began working in a local factory, and she and her children
moved in with her mother. About 6 weeks before her initial
admission, Ms. V started feeling that drug dealers and gangsters
were out to hurt her and that people were poisoning her food. She
also did not let her children eat, fearing they would die from food
poisoning.
 She was admitted to the hospital for 2 weeks but did not receive any
medications at that time. Three weeks after discharge, she was
readmitted with the same symptoms and also experienced thought
broadcasting, thought insertion, and olfactory hallucinations.
 She was treated with haloperidol (Haldol) and was discharged after
1 month. She later moved to Florida with her mother and children,
worked full time, and remained free of symptoms without treatment
for 9 years. At that time, she again became psychotic, but after
treatment with olanzapine (Zyprexa) for 1 month, she recovered
fully and resumed her usual social and occupational functioning.
 Differential Diagnosis
 It is important to first differentiate
schizophreniform disorder from psychoses that
can arise from medical conditions. This is
accomplished by taking a detailed history and
physical examination and, when indicated,
performing laboratory tests or imaging studies.
A detailed history of medication use, including
over-the-counter medications and herbal
products, is essential because many
therapeutic agents can also produce an acute
psychosis. Although it is not always possible to
distinguish substance-induced psychosis from
other psychotic disorders cross-sectionally, a
rapid onset of psychotic symptoms in a patient
with a significant substance history should raise
the suspicion of a substance-induced psychosis.
A detailed substance use history and
toxicological screen are also important for
 The duration of psychotic symptoms is
one of the factors that distinguish
schizophreniform disorder from other
syndromes. Schizophrenia is diagnosed if
the duration of the prodromal, active, and
residual phases lasts for more than 6
months, whereas symptoms that occur
for less than 1 month indicate a brief
psychotic disorder. In DSM-IV-TR, a
diagnosis of brief psychotic disorder does
not require that a major stressor be
present.
 To distinguish mood disorders with
psychotic features from schizophreniform
disorder is sometimes difficult. Further
more, schizophreniform disorder and
schizophrenia can be highly comorbid with
mood and anxiety disorders. Additional
confounds are that mood symptoms, such
as loss of interest and pleasure, may be
difficult to distinguish from negative
symptoms, avolition, and anhedonia.
Some mood symptoms may also be
present during the early course of
schizophrenia. A thorough longitudinal
history is important in elucidating the
diagnosis because the presence of
psychotic symptoms exclusively during
periods of mood disturbance is an
indication of a primary mood disorder.
 Course and Prognosis
 The course of schizophreniform disorder, for the
most part, is defined in the criteria. It is a
psychotic illness lasting more than 1 month and
less than 6 months. The real issue is what
happens to persons with this illness over time.
Most estimates of progression to schizophrenia
range between 60 and 80 percent. What happens
to the other 20 to 40 percent is currently not
known. Some will have a second or third episode
during which they will deteriorate into a more
chronic condition of schizophrenia. A few,
however, may have only this single episode and
then continue on with their lives, which is clearly
the outcome desired by all clinicians and family
members, although it is probably a rare
occurrence and should not be held out as likely.
 ICD-10 Diagnostic Guidelines for
Acute Schizophrenia-Like Psychotic
Disorder
 The onset of psychotic symptoms must be
acute (2 weeks or less from a
nonpsychotic to a clearly psychotic state).
 Symptoms that fulfill the criteria of
schizophrenia must have been present for
the majority of time.
 The criteria for acute polymorphic
psychotic disorder are not fulfilled.
 If the psychotic symptoms last for more
than 1 month, then the diagnosis should
be changed to schizophrenia.
Schizoaffective Disorder
 As the term implies, schizoaffective disorder
has features of both schizophrenia and
affective disorders (now called mood
disorders). In current diagnostic systems,
patients can receive the diagnosis of
schizoaffective disorder if they fit into one of
the following six categories:
 (1) patients with schizophrenia who have
mood symptoms;
 (2) patients with mood disorder who have
symptoms of schizophrenia;
 (3) patients with both mood disorder and
schizophrenia
 (4) patients with a third psychosis unrelated to
schizophrenia and mood disorder;
 (5) patients whose disorder is on a continuum
 (6) patients with some combination of the
above. The revised fourth edition of the
Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV-TR) incorporated the
stricter time frame of 1 month's duration of
schizophrenia symptoms and required an
uninterrupted period of illness during which
at some time, either there is a Major
Depressive Episode, a Manic Episode, or a
Mixed Episode concurrent with symptoms
that meet Criterion A for Schizophrenia.
DSM-IV-TR also elaborated more on the
criterion of duration of the mood symptoms
relative to the psychotic symptoms. In the
tenth revision of International Statistical
Classification of Diseases and Related
Health Problems (ICD-10), schizoaffective
disorder is a distinct entity and can be
applied to patients who have co-occurring
mood symptoms and schizophrenic-like
mood-incongruent psychosis.
 DSM-IV-TR Diagnostic Criteria for Schizoaffective
Disorder

 An uninterrupted period of illness during which, at some time,


there is either a major depressive episode, a manic episode, or a
mixed episode concurrent with symptoms that meet Criterion A for
schizophrenia.
Note: The major depressive episode must include Criterion A1:
depressed mood.
 During the same period of illness, there have been delusions or
hallucinations for at least 2 weeks in the absence of prominent
mood symptoms.
 Symptoms that meet criteria for a mood episode are present for a
substantial portion of the total duration of the active and residual
periods of the illness.
 The disturbance is not due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication) or a general
medical condition.
 Specify type:
      Bipolar type: if the disturbance includes a manic or a mixed
episode (or a manic or a mixed episode and major depressive
episodes)
      Depressive type: if the disturbance only includes major
depressive episodes
 Mrs. P was a 47-year-old, divorced, unemployed woman who
lived alone and was chronically psychotic despite treatment with
olanzapine, 20 mg per day, and citalopram (Celexa), 20 mg per
day.
 She believed that she was getting messages from God and the
police department to go on a mission to fight drug dealers. She
also believed that the Mafia was trying to stop her in this
pursuit.
 The onset of her illness began at 20 years of age, when she
experienced the first of several depressive episodes.
 She also described periods when she felt more energetic,
talkative, had decreased need for sleep, and was more active,
sometimes cleaning her house the whole night. Approximately 4
years after the onset of her symptoms, she began to hear voices
that became stronger when she got depressed, but were still
present and continued to disturb her even when her mood was
euthymic. Approximately 10 years after her illness began, she
developed the belief that policemen were everywhere and that
the neighbors were spying on her. She was hospitalized
voluntarily. Two years later, she had another depressive
episode, and the voices told her she could not live in her
apartment. She was tried on lithium, antidepressants, and
antipsychotic medications but continued to be chronically
symptomatic with mood symptoms as well as psychosis.
(Courtesy of Shmuel Fennig, M.D., Laura J. Fochtmann, M.D., and
Gabrielle A. Carlson, M.D.)
 Differential Diagnosis
 The psychiatric differential diagnosis includes all the
possibilities usually considered for mood disorders
and for schizophrenia. In any differential diagnosis of
psychotic disorders, a complete medical workup
should be performed to rule out organic causes for
the symptoms. A history of substance use (with or
without positive results on a toxicology screening
test) may indicate a substance-induced disorder.
Preexisting medical conditions, their treatment, or
both can cause psychotic and mood disorders. Any
suspicion of a neurological abnormality warrants
consideration of a brain scan to rule out anatomical
pathology and an electroencephalogram (EEG) to
determine any possible seizure disorders (e.g.,
temporal lobe epilepsy). Psychotic disorder caused
by seizure disorder is more common than that seen
in the general population. It tends to be
characterized by paranoia, hallucinations, and ideas
of reference. Patients with epilepsy with psychosis
are believed to have a better level of function than
patients with schizophrenic spectrum disorders.
 ICD-10 Diagnostic Criteria for
Schizoaffective Disorders Note:
 This diagnosis depends upon an approximate
balance between the number, severity, and
duration of the schizophrenic and affective
symptoms.
G1. The disorder meets the criteria for one of
the affective disorders of moderate or severe
degree, as specified for each category.
G2. Symptoms from at least one of the groups
listed below must be clearly present for most of
the time during a period of at least 2 weeks
(these groups are almost the same as for
schizophrenia):
 Thought echo, thought insertion or withdrawal,
thought broadcasting (Criterion G1[1]a for
paranoid, hebephrenic, or catatonic
schizophrenia);
 Delusions of control, influence, or passivity,
 Hallucinatory voices giving a running
commentary on the patient's behavior or
discussing the patient among themselves, or
other types of hallucinatory voices coming
from some part of the body (Criterion G1[1]c
for paranoid, hebephrenic, or catatonic
schizophrenia);
 Persistent delusions of other kinds that are
culturally inappropriate and completely
impossible, but not merely grandiose or
persecutory (Criterion G1[1]d for paranoid,
hebephrenic, or catatonic schizophrenia), e.g.,
has visited other worlds; can control the clouds
by breathing in and out; can communicate with
plants or animals without speaking;
 Grossly irrelevant or incoherent speech, or
frequent use of neologisms (a marked form of
Criterion G1[2]b for paranoid, hebephrenic, or
 Intermittent but frequent appearance of some forms of catatonic
behavior, such as posturing, waxy flexibility, and negativism
(Criterion G1[2]c for paranoid, hebephrenic, or catatonic
schizophrenia).
 G3. Criteria G1 and G2 above must be met within the same
episode of the disorder, and concurrently for at least part of the
episode. Symptoms from both G1 and G2 must be prominent in
the clinical picture.
G4. Most commonly used exclusion clause. The disorder is not
attributable to organic mental disorder, or to psychoactive
substance-related intoxication, dependence, or
withdrawal.Schizoaffective disorder, manic type
 The general criteria for schizoaffective disorder must be met.
 Criteria for a manic disorder must be met.
 Other schizoaffective disorders
Schizoaffective disorder, unspecifiedComments
If desired, further subtypes of schizoaffective disorder may be
specified, according to the longitudinal development of the
disorder, as follows:
   Concurrent affective and schizophrenic symptoms only
   Symptoms as defined in Criterion G2 for schizoaffective
disorders
   Concurrent affective and schizophrenic symptoms beyond the
duration of affective symptoms(Reprinted with permission from
World Health Organization. The ICD-10 Classification of Mental
 Treatment
 Mood stabilizers are a mainstay of treatment for
bipolar disorders and would be expected to be
important in the treatment of patients with
schizoaffective disorder. One study that compared
lithium with carbamazepine (Tegretol) found that
carbamazepine was superior for schizoaffective
disorder, depressive type, but found no difference in
the two agents for the bipolar type. In practice,
however, these medications are used extensively
alone, in combination with each other, or with an
antipsychotic agent. In manic episodes, patients who
are schizoaffective should be treated aggressively
with dosages of a mood stabilizer in the middle to
high therapeutic blood concentration range. As the
patient enters maintenance phase, the dosage can be
reduced to low to middle range to avoid adverse
effects and potential effects on organ systems (e.g.,
thyroid and kidney) and to improve ease of use and
compliance. Laboratory monitoring of plasma drug
concentrations and periodic screening of thyroid,
kidney, and hematological functioning should be
 By definition many patients who are
schizoaffective have major depressive episodes.
Treatment with antidepressants mirrors
treatment of bipolar depression. Care should be
taken not to precipitate a cycle of rapid switches
from depression to mania with the
antidepressant. The choice of antidepressant
should take into account previous antidepressant
successes or failures. Selective serotonin
reuptake inhibitors (e.g., fluoxetine [Prozac] and
sertraline [Zoloft]) are often used as first-line
agents because they have less effect on cardiac
status and have a favorable overdose profile.
Agitated or insomniac patients, however, may
benefit from a tricyclic drug. As in all cases of
intractable mania, the use of electroconvulsive
therapy (ECT) should be considered. As
mentioned, antipsychotic agents are important in
the treatment of the psychotic symptoms of