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SUBSTANCE RELATED DISORDER

GANGGUAN MENTAL PERILAKU PENYALAHGUNAAN Zat


Tujuan : Mampu diagnose klinis Mampu terapi awal Merujuk kasus emergency maupun non emergency

Tugas Baca kaplan edisi 10

Gangguan mental, perilaku akibat zat : Penyalahgunaan obat Sindroma ketergantungan Gangguan Psikotik Keadaan putus obat
Penyalahgunaan zat tidak menyebabkan ketergantungan diagnoses (F 55) : antidepresan (F 55,0),pencahar( F 55.1) , aspirin, analgetika (F 55.2), antasida (F 55.3), vitamin (F 55.4), jamu( F 55.6).

PPDGJ III / PEDOMAN PENGGOLONGAN & DIAGNOSIS GANGGUAN JIWA DI INDONESIA III (1994-2004) AKSIS I : GANGGUAN KLINIS KONDISI LAIN YG JADI FOKUS PERHATIAN KLINIS KODE TAMBAHAN ( Z03.2 & R69) AKSIS II : GANGGUAN KEPRIBADIAN RETRADASI MENTAL AKSIS III : KONDISI MEDIK UMUM AKSIS IV : MASALAH PSIKOSOSIAL & LINGKUNGAN AKSIS V : PENILAIAN FUNGSI SECARA GLOBAL.

Axis l: a. Gangguan mental dan Perilaku akibat penggunaan alkohol , intoksikasi akut dg delerium ( F10.03).( gangguan klinik) b. Masalah berkaitan dg kelompok pendukung krn kekacauan serta perpisahan dan perceraian keluarga ( fokus perhatian klinik) Axis II : Ciri kepribadian dissosial (antisosial) Axis III : Intoksikasi , Delerium Axis IV : Masalah keluarga berkaitan kelompok pendukung. Axis V : GAF Scale 31-40 ( saat MRS)

Komorbiditas ( diagnose ganda ) pada penyalahgunaan atau ketergantungan zat : Gangguan kepribadian antisosial ditandai : kurang puas dgn kehidupan , perilaku impulsif , isolasi sosial. Gangguan suasana perasaan ( ide bunuh diri atau pikiran bunuh diri ) Gangguan kecemasan ( sosial fobia ,gangguan panik ) dan zat yg sering digunakan golongan ampetamin , kokain , kafein.

Masalah ancamam penyebaran HIV/AID dapat terjadi Injecting Drug User / IDU : Menghisap opium->injeksi heroin / opiat lebih sering bergantian. Amfetamin ditelan-> injeksi ( eksekutif muda bekerja lebih lama tanpa lelah atau wanita pengurangan berat badan. Injeksi Steroid penambahan stamina atlet Injeksi silikone (memperindah payudara, hidung, bibir).

Kepribadian dependent ditandai pengukuran rasa kebahagian membutuhkan pengakuan dari orang lain ,sehingga tidak bisa mengambil sikap tegas , kurang percaya diri. Adanya masalah hubungan orang tua dengan anak yg disebabkan orang tua terlalu menuntut nilai tinggi membuat kebingungan peran anak. Riwayat anak dengan gg pemusatan perhatian , yg saat dewasa dapat menyebabkan gg penyalahgunaan zat , dll.

INTRODUCTION

Cover substance dependence and substance abuse with descriptions of the clinical phenomena associated with the use of 11 designated classes of pharmacological agents: - alcohol - amphetamines or similarly acting agents - caffeine - cannabis - cocaine - hallucinogens - inhalants - nicotine - opioids - phencyclidine (PCP) or similar agents - a group that includes sedatives, hypnotics, and anxiolytics - a residual 12th category includes a variety of agents not in the 11 designated classes, such as anabolic steroids and nitrous oxide

TERMINOLOGY
Two concepts have been used to define aspects of dependence: behavioral and physical
- behavioral dependence, substance-seeking

activities and related evidence of pathological use patterns are emphasized - physical dependence refers to the physical (physiological) effects of multiple episodes of substance use

Somewhat related to dependence are the related words addiction and addict

Addict has acquired a distinctive(tersendiri), unseemly,


Addiction has also been trivialized in popular
usage, as in the terms TV addiction and money addiction. Although these connotations have helped the officially sanctioned nomenclature to avoid use of the word addiction, common neurochemical and neuroanatomical substrates may be found among all addictions, whether to substances or to gambling, sex, stealing, or eating

and pejorative connotation that ignores the concept of substance abuse as a medical disorder

These various addictions may have similar effects on the activities of specific reward areas of the brain, such as the ventral tegmental area, the locus ceruleus, and the nucleus accumbens

Psychological dependence, also referred to as habituation, is characterized by a continuous or intermittent craving for the substance to avoid a dysphoric state

Denial

Family members, as with the substance users themselves, often behave as if the substance use that is causing obvious problems were not really a problem; that is, they engage in denial The reasons for the unwillingness to accept the obvious vary. Sometimes denial is self-protecting, in that the family members believe that if a drug or alcohol problem exists, then they are responsible

As with the addicts themselves, codependent family members seem unwilling to accept the notion that outside intervention is needed and, despite repeated failures, continue to believe that greater willpower and greater efforts at control can restore tranquility. When additional efforts at control fail, they often attribute the failure to themselves rather than to the addict or the disease process, and along with failure come feelings of anger, lowered self-esteem, and depression

In definitions stressing physical dependence, ideas of tolerance or withdrawal appear in the classification criteria

DSM-IV-TR Criteria for Substance Withdrawal


A. The development of a substance-specific syndrome due to the cessation of (or reduction in) substance use that has been heavy and prolonged. B. The substance-specific syndrome causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

DSM-IV-TR Criteria for Substance Intoxication


A. The development of a reversible substance-specific syndrome due to recent ingestion of (or exposure to) a substance. Note: Different substances may produce similar or identical syndromes. B. Clinically significant maladaptive behavioral or psychological changes that are due to the effect of the substance on the central nervous system (e.g., belligerence, mood lability, cognitive impairment, impaired judgment, impaired social or occupational functioning) and develop during or shortly after use of the substance. C. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

DSM-IV-TR Criteria for Substance Abuse


A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12month period: 1. recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household) 2. recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use) 3. recurrent substance-related legal problems (e.g., arrests for substancerelated disorderly conduct) 4. continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights) B. The symptoms have never met the criteria for Substance Dependence for this class of substance

COURSE MODIFIERS FOR SUSTANCE DEPENDENCE

DSM-IV-TR Criteria for Substance Dependence


A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period: 1. tolerance, as defined by either of the following: a. a need for markedly increased amounts of the substance to achieve intoxication or desired effect. b. markedly diminished effect with continued use of the same amount of the substance 2. withdrawal, as manifested by either of the following: a. the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances) b. the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms 3. the substance is often taken in larger amounts or over a longer period than was intended 4. there is a persistent desire or unsuccessful efforts to cut down or control substance use 5. a great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects 6. important social, occupational, or recreational activities are given up or reduced because of substance use 7. the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)

Specify if:
With Physiological Dependence: evidence of tolerance or withdrawal (i.e., either Item 1 or 2 is present) Without Physiological Dependence: no evidence of tolerance or withdrawal (i.e., neither Item 1 nor 2 is present)

Course specifiers :
- Early Full Remission - Early Partial Remission - Sustained Full Remission - Sustained Partial Remission - On Agonist Therapy -In a Controlled Environment

Early full remission

This specifier is used if, for at least 1 month, but for less than 12 months, no criteria for dependence or abuse have been met

Early partial remission

This specifier is used if, for at least 1 month, but less than 12 months, one or more criteria for dependence or abuse have been met (but the full criteria for dependence have not been met)

Sustained(berlanjut) full remission

This specifier is used if none of the criteria for dependence or abuse has been met at any time during a period of 12 months or longer

Sustained partial remission

This specifier is used if full criteria for dependence have not been met for a period of 12 months or longer; however, one or more criteria for dependence or abuse have been met

The following specifiers apply if the individual is on agonist therapy or in a controlled environment:

On agonist therapy

This specifier is used if the individual is on a prescribed agonist medication, and no criteria for dependence or abuse have been met for the class of medication for at least the past month (except tolerance to, or withdrawal from, the agonist) This category also applies to those being treated for dependence using a partial agonist or an agonist/antagonist

In a controlled environment - This specifier is used if the individual is in an


environment where access to alcohol and controlled substances is restricted, and no criteria for dependence or abuse have been met for at least the past month

EPIDEMIOLOGY

As of 2004, an estimated 22.5 million persons over the age of 12 years (about 10 percent of the total US population) were classified as suffering from a substance-related disorder. Of this group, about 15 million were dependent on, or abused, alcohol

Dependence on, or abuse of, specific substances within the past year, 2004. (From National Survey on Drug Use and Abuse, with permission

Illicit Drug Use in Lifetime, Past Year, and Past Month, by Detailed Age Category: Percentages, 2003 and 2004
Time Period Lifetime Age Category TOTAL 2003 46.4 2004 45.8 Past Year 2003 14.7 2004 14.5 Past Month 2003 8.2 2004 7.9

12 13
14 15 16 17 18 19 20

12.2 18.7
26.3 34.2 43.8 48.4 53.5 58.3 62.0

11.2 18.4
25.2 34.7 42.5 48.4 53.4 56.6 59.0

6.2 11.9
18.7 25.2 33.2 36.1 38.2 39.9 40.3

6.7 11.6
17.8 24.6 31.0 34.9 38.8 38.6 38.1

2.7 4.9
8.5 13.3 18.6b 19.7 22.6 23.5 24.0

2.8 4.6
9.0 12.7 15.5 19.1 21.2 22.8 21.3

21 22 23 24 25 26-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 > 65

61.6 64.0 63.4a 62.3 60.1 57.9 56.8 61.7 65.3 62.3 52.0 38.3 23.8 9.9

62.3 62.9 59.5 59.8 60.5 60.0 54.5 59.4 64.9 61.8 56.3 38.2 24.2 8.3

35.0 33.5 32.2a 30.1 25.9 23.6 16.6 15.0 14.0 12.6 7.4 4.4 2.9 0.7

36.6 35.1 28.3 27.6 26.7 23.5 15.7 14.1 14.4 11.8 9.0 5.1 2.0 0.9

20.7 19.6 18.0a 17.2 15.7 13.4 8.8 8.4 8.1 6.8 3.9 2.0 1.1 0.6

21.7 20.5 15.4 16.2 15.2 13.2 9.4 7.2 7.5 6.8 4.8 2.6 1.1 0.4

The rate for dependence or abuse was 1.3 percent at age 12, and rates generally increased until the highest rate (25.4 percent) at age 21. After age 21, a general decline occurred with age. By age 65, only about 1 percent of persons have used an illicit substance

ETIOLOGY

PSYCHODYNAMIC FACTORS

According to classic theories, substance abuse is a masturbatory equivalent (some heroin users describe the initial as similar to a prolonged sexual orgasm), a defense against anxious impulses, or a manifestation of oral regression (i.e., dependency)
Recent psychodynamic formulations relate substance use as a reflection of disturbed ego functions (i.e., the inability to deal with reality

LEARNING AND CONDITIONING

Some drugs may sensitize neural systems to the reinforcing effects of the drug Eventually, the paraphernalia (needles, bottles, cigarette packs) and behaviors associated with substance use can become secondary reinforcers, as well as cues(isyarat) signaling availability of the substance, and in their presence, craving or a desire to experience the effects increases Drug users respond to the drug-related stimuli with increased activity in limbic regions, including the amygdala and the anterior cingulate

GENETIC FACTOR

Strong evidence from studies of twins, adoptees, and siblings brought up separately indicates that the cause of alcohol abuse has a genetic component
Researchers recently have used restriction fragment length polymorphism (RFLP) in the study of substance abuse and substance dependence, and associations to genes that affect dopamine production have been

postulated.

NEUROCHEMICAL FACTORS

Receptors and Receptor Systems

Researchers have identified particular neurotransmitters or neurotransmitter receptors involved with most substances of abuse

A person with too little endogenous opioid activity (e.g., low concentrations of endorphins) or with too much activity of an endogenous opioid antagonist may be at risk for developing opioid dependence

This pathway is probably involved in the sensation of reward and may be the major mediator of the effects of such substances as amphetamine and cocaine The locus ceruleus, the largest group of adrenergic neurons, probably mediates the effects of the opiates and the opioids. These pathways have collectively been called the brain-reward circuitry

SUBTANCES

ALCOHOL RELATED DISORDER

Alcohol use disorders are common lethal conditions that often masquerade(menyamarkan) as other psychiatric syndromes Alcohol intoxication can cause irritability, violent behavior, feelings of depression, and, in rare instances, hallucinations and delusions Long-term, escalating levels of alcohol consumption can produce tolerance as well as such intense adaptation of the body that cessation of use can precipitate a withdrawal syndrome usually marked by insomnia, evidence of hyperactivity of the autonomic nervous system, and feelings of anxiety

Alcohol Epidemiology

Condition Ever had a drink

Population (%) 90

Current drinker
Temporary problems

60-70
40+

Abusea
Dependencea
aTwenty

Male: 10+ Female: 5+


Male: 10 Female: 3-5

to 30 percent of psychiatric patients

Etiology of alcohol related disorder

Psychological Theories use of alcohol to reduce tension, increase feelings of


power, and decrease the effects of psychological pain

Psychodynamic Theories To help them deal with self-punitive(menghukum)


harsh superegos and to decrease unconscious stress levels Classic psychoanalytical theory hypothesizes that at least some alcoholic people may have become fixated at the oral stage of development and use alcohol to relieve their frustrations by taking the substance by mouth

Behavioral Theories
Drink again after the first experience with alcohol

and to continue to imbibe(meminum) despite problems

Sociocultural Theories
Theorists hypothesize that ethnic groups lead to alcohol abuse and dependence

Genetic Theories
Evidence show that genetic lead to alcohol abuse and dependence

Keadaan putus alkohol Onset 12 jam sesudah minum terakhir Puncak 48-72 jam Gejala: -halusinasi, ilusi - mual-muntah - flushed face -craving for alcohol - imbalance electrolit

AMPHETAMINE (or AMPHETAMINELIKE)- RELATED DISORDER

Amphetamines and amphetamine-like drugs are the most widely used illicit(gelap) substances in the United States, Asia, Great Britain, Australia, and several other western European countries As a general class, the amphetamines are referred to as analeptics, sympathomimetics, stimulants, and psychostimulants Amphetamine-like substances are ephedrine, pseudoephedrine, and phenylpropanolamine (PPA). PPA can dangerously exacerbate hypertension, precipitate a toxic psychosis, cause intestinal infarction, or result in death

The classic amphetamines causing the release of catecholamines, particularly dopamine, from presynaptic terminals The effects are particularly potent for the dopaminergic neurons projecting from the ventral tegmental area to the cerebral cortex and the limbic areas This pathway has been termed the reward circuit pathway, and its activation is probably the major addicting mechanism for the amphetamines The designer amphetamines cause the release of catecholamines (dopamine and norepinephrine) and of serotonin, the neurotransmitter implicated as the major neurochemical pathway for hallucinogens

NARKOTIKA

PENDAHULUAN

Narkotika terdiri atas 3 golongan yaitu: Opioid, Tanaman Ganja dan Kokain Opioida adalah sejenis narkotika yang mempunyai potensi ketergantungan yang paling kuat bila dibandingkan dengan jenis narkotika lainnya.

OPIOID

Golongan opioid turunan opium dan zat sintetisnya: opium, morfin, diasetilmorfin atau diamorfin dan lain-lain Opioid efek menekan ("depresan") CNS, me spontan aktivitas neuron, pusing, perubahan perasaan dan kesadaran berkabut. Penggunaan opioida dengan cara: dragon, sniffing , puff, dan jarum suntik. Intoksikasi opioidaoverdosis kematian. Intoksikasi Opioid

OPIOID LANJUTAN
Terapi Detoksifikasi Opioida terapi awal dari ketergantungan opioida mengeluarkan opioida dari dalam tubuh (3 hari sampai beberapa minggu). Langkah dan beberapa alternatif pada terapi detoksifikasi adalah: 1. Tentukan diagnosis yang tepat dengan penemuan gejalagejala objektif putus opioida 2. Tujuan utama dari terapi detioksifikasi opioida adalah mengurangi penderitaan pasien, mencegah komplikasi medik dan menghindarkan pasien kembali menggunakan opioida 3. Metadon adalah opioida sintetis yang bersifat agonis. Pemberian metadon merupakan standar terapi di banyak negaradianggap sebagai substitusi opioida dan do. bertahap. Pada fase awal untuk menghilangkan gejalagejala abstinensia, dosis metadon antara 20-40 mg per hari.

NIKOTIN
Nikotin merupakan stimulansia yang bekerja pada reseptor nikotin pada susunan saraf pusat Nikotin mempunyai efek pada sistemsistem kardiovaskuler, gastrointestinalis, respiratorius dan endokrin

NIKOTIN
Nikotin merupakan stimulansia yang bekerja pada reseptor nikotin pada susunan saraf pusat Nikotin mempunyai efek pada sistemsistem kardiovaskuler, gastrointestinalis, respiratorius dan endokrin