Laporan PBL kelompok 1 modul gangguan tidur.docx

LAPORAN PBL MODUL GANGGUAN TIDUR BLOK NEUROPSIKIATRI

KELOMPOK 1 Dosen Pembimbing : dr. Innah Mutmainnah Musa 110 2014 0137

Icha Wulandari Lapata

110 2016 0004

Andi M. Shofwatul Islam Hafid

110 2016 0029

Indra Aprianto

110 2016 0041

Roza Linda Duarsa

110 2016 0056

Anastasia Nugraha Pratiwi

110 2016 0064

Aulia Wahyu Ramdani

110 2016 0081

Hasmaul Husna Amin

110 2016 0109

Aqilla Nadya Zalzabila

110 2016 0118

Ninadiyah Nurul Azizah

110 2016 0121

Ayu Azizah Syen

FAKULTAS KEDOKTERAN UNIVERSITAS MUSLIM INDONESIA MAKASSAR 2018

1

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MODUL 3 GANGGUAN TIDUR 

SKENARIO 1

Seorang laki-laki berusia 28 tahun datang ke dokter dengan keluhan sulit memulai tidur, sering terbangun dini hari sejak 2 bulan yang lalu. Ia mengeluh sakit kepala dan mudah lelah, terus-menerus merasa sedih, energi juga berkurang, kurang minat terhadap hobi yang biasanya, kemampuan berkonsentrasi berkurang, kadang-kadang muncul ide-ide bunuh diri. Dia mengatakan bahwa dia mendengar suara-suara

gurunya yang mengatakan “dia tidak akan berhasil” dan kadang -

kadang mengomentari tentang tingkah lakunya yang selalu negatif. Dia mengatakan bahwa dia telah mendengar suara ini selama beberapa tahun. Dia menyangkal menggunakan obat-obatan atau alcohol dan dia tidak mempunyai masalah medis.

KATA SULIT :

Tidak ada

KATA KUNCI :

1. Laki-laki berusia 28 tahun 2. Keluhan sulit memulai tidur dan sering terbangun dini hari sejak 2 bulan yang lalu 3. Sakit kepala dan mudah lelah, terus-menerus merasa sedih, energi juga  berkurang, kurang minat terhadap hobi yang biasanya, kemampuan  berkonsentrasi berkurang, kadang-kadang muncul muncul ide-ide bunuh diri

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4. Pasien mendengar suara-suara

gurunya yang mengatakan “dia tidak akan

 berhasil” dan kadang-kadang mengomentari tentang tingkah lakunya yang selalu negatif 5. Pasien telah mendengar suara ini selama beberapa tahun 6. Pasien menyangkal menggunakan obat-obatan atau alcohol dan dia tidak mempunyai masalah medis

PERTANYAAN :

1. Apa yang dimaksud tidur? 2. Bagaimana klasifikasi gangguan tidur? 3. Bagaimana patofisiologi gangguan tidur? 4. Apa yang menyebabkan terjadinya gangguan tidur? 5. Bagaimana hubungan gangguan tidur dan perubahan perilaku sesuai dengan skenario? 6. Bagaimana langkah-langkah diagnosis gangguan tidur? 7. Apa diagnosis banding dari gangguan tidur? 8. Bagaimana penatalaksanaan awal gangguan tidur? 9. Apa perspektif islam yang sesuai dengan skenario?

JAWABAN :

1. Apa yang dimaksud tidur? Jawab :

Suatu keadaan bawah sadar dimana seseorang masih dapat dibangunkan dengan pemberian rangsang sensorik atau dengan rangsang lainnya. Setidak-tidaknya kita membutuhkan 7 s/d 9 jam setiap malamnya agar tubuh kita dapat berfungsi dengan baik.

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Fisiologi tidur :

Setiap makhluk memiliki irama kehidupan yang sesuai dengan masa rotasi bola dunia yang dikenal dengan nama irama sirkadian. Irama sirkadian bersiklus 24 jam. Pusat kontrol irama sirkadian terletak pada  bagian ventral anterior hypothalamus. Sistem yang mengatur siklus atau  perubahan dalam tidur adalah  Reticular Activating System (RAS ) dan  Bulbar Synchronizing Regional Regional (BSR) yang (BSR)  yang terletak pada batang otak. Menggunakan

elektroensefalogram

(EEG),

elektro-okulogram

(EOG), dan elektromiogram (EMG), didapatkan perbedaan gelombang  pada saat s aat terjaga dan pada saat tidur, yaitu terbagi terba gi menjadi dua fase yaitu  pergerakan mata yang cepat atau  Rapid Eye Movement (REM)  (REM)  dan  pergerakan mata yang tidak cepat atau Non atau  Non Rapid Eye Movement (NREM). Tidur diawali dengan fase NREM yang terdiri dari empat stadium lalu diikuti oleh fase REM. Tipe NREM dibagi dalam 4 stadium yaitu: 1.

Tidur stadium satu Fase ini merupakan antara fase terjaga dan fase awal tidur. Fase ini didapatkan kelopak mata tertutup, tonus otot berkurang dan tampak gerakan bola mata kekanan dan kekiri. Fase ini hanya  berlangsung 3-5 menit dan mudah sekali dibangunkan. Gambaran EEG biasanya terdiri dari gelombang campuran alfa, betha dan kadang gelombang theta dengan amplitudo yang rendah. Tidak didapatkan adanya gelombang sleep spindle dan kompleks K.

2.

Tidur stadium dua Pada fase ini didapatkan bola mata berhenti bergerak, tonus otot masih berkurang, tidur lebih dalam dari pada fase pertama. Gambaran EEG terdiri dari gelombang theta simetris. Terlihat

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3.

Tidur stadium tiga Fase ini tidur lebih dalam dari fase sebelumnya. Gambaran EEG terdapat lebih banyak gelombang delta simetris antara 25%50% serta tampak gelombang sleep spindle.

4.

Tidur stadium empat Merupakan tidur yang dalam serta sukar dibangunkan. Gambaran EEG didominasi oleh gelombang delta sampai 50% tampak gelombang sleep spindle. Fase tidur NREM, ini biasanya  berlangsung antara 70 menit sampai 100 menit, setelah itu akan masuk ke fase REM. Pada waktu REM jam pertama prosesnya berlangsung lebih cepat

dan menjadi lebih insten dan panjang saat menjelang pagi atau bangun. Pola tidur REM ditandai adanya gerakan bola mata yang cepat, tonus otot yang sangat rendah, apabila dibangunkan hampir semua organ akan dapat menceritakan mimpinya, denyut nadi bertambah dan pada laki-laki terjadi eraksi penis, tonus otot menunjukkan relaksasi yang dalam. Keadaan jaga atau bangun sangat dipengaruhi oleh sistim  ARAS (Ascending Reticulary Activity System). Aktifitas ARAS ini sangat dipengaruhi oleh aktifitas neurotransmiter seperti sistem serotoninergik, noradrenergik, kholonergik, histaminergik. a.

Sistem serotonergik Hasil

serotonergik

sangat

dipengaruhi

oleh

hasil

metabolisma asam amino trypthopan. Dengan bertambahnya  jumlah tryptopan, maka jumlah serotonin yang terbentuk juga meningkat akan menyebabkan keadaan mengantuk/tidur. Bila serotonin

dari

tryptopan

terhambat

pembentukannya,

maka

terjadikeadaan tidak bisa tidur/jaga. Menurut beberapa peneliti

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raphe dorsalis di batang otak, yang mana terdapat hubungan aktifitas serotonis dinukleus raphe dorsalis dengan tidur REM.  b.

Sistem Adrenergik  Neuron-neuron yang terbanyak mengandung norepineprin terletak di badan sel nukleus cereleus di batang otak. Kerusakan sel neuron pada lokus cereleus sangat mempengaruhi penurunan atau hilangnya

REM

tidur.

Obat-obatan

yang

mempengaruhi

 peningkatan aktifitas neuron noradrenergik akan menyebabkan  penurunan yang jelas pada tidur REM dan peningkatan keadaan  jaga. c.

Sistem Kholinergik membuktikan dengan pemberian prostigimin intra vena dapat

mempengaruhi

episode

tidur

REM.

Stimulasi

jalur

kholihergik ini, mengakibatkan aktifitas gambaran EEG seperti dalam keadaan jaga. Gangguan aktifitas kholinergik sentral yang  berhubungan dengan perubahan tidur ini terlihat pada orang depresi, sehingga terjadi pemendekan latensi tidur REM. Pada obat antikolinergik (scopolamine) yang menghambat pengeluaran kholinergik dari lokus sereleus maka tamapk gangguan pada fase awal dan penurunan REM. d.

Sistem histaminergik Pengaruh histamin sangat sedikit mempengaruhi tidur.

e.

Sistem hormon Pengaruh hormon terhadap siklus tidur dipengaruhi oleh  beberapa hormon seperti ACTH, GH, TSH, dan LH. Hormon hormon ini masing-masing disekresi secara teratur oleh kelenjar  pituitary anterior melalui hipotalamus patway. Sistem ini secara teratur mempengaruhi pengeluaran neurotransmiter norepinefrin,

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2. Bagaimana klasifikasi gangguan tidur? Jawab :

Klasifikasi gangguan tidur : 1. Gangguan tidur primer Gangguan tidur primer adalah gangguan tidur yang bukan disebabkan oleh gangguan mental lain, kondisi medik umum, atau zat. Gangguan tidur ini dibagi dua yaitu disomnia dan parasomnia. Disomnia ditandai dengan gangguan pada jumlah, kualitas, dan waktu tidur. Parasomnia dikaitkan dengan perilaku tidur atau peristiwa fisiologis yang dikaitkan dengan tidur, stadium tidur tertentu atau  perpindahan tidur-bangun. Disomnia terdiri dari insomnia primer, hipersomnia primer, narkolepsi, gangguan tidur yang berhubungan dengan pernafasan, gangguan ritmik sirkadian tidur, dan disomnia yang tidak dapat diklasifikasikan. Parasomnia terdiri dari gangguan mimpi buruk, gangguan teror tidur, berjalan saat tidur, dan parasomnia yang tidak dapat diklasifikasikan. 2. Gangguan tidur terkait gangguan mental lain Gangguan tidur terkait gangguan mental lain yaitu terdapatnya keluhan gangguan

tidur yang menonjol yang

diakibatkan oleh

gangguan mental lain (sering karena gangguan mood) tetapi tidak memenuhi syarat untuk ditegakkan sebagai gangguan tidur tersendiri. Ada dugaan bahwa mekanisme patofisiologik yang mendasari

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4. Gangguan tidur akibat zat Yaitu adanya keluhan tidur yang menonjol akibat sedang menggunakan

atau

menghentikan

penggunaan

zat

(termasuk

medikasi). Penilaian sistematik terhadap seseorang yang yang mengalami keluhan tidur seperti evaluasi bentuk gangguan tidur yang spesifik, gangguan mental saat ini, kondisi medik umum, dan zat atau medikasi yang digunakan, perlu dilakukan.

3. Bagaimana patofisiologi gangguan tidur? Jawab :

Tidur dibagi menjadi dua fase yaitu pergerakan mata yang cepat atau Rapid Eye Movement (REM) dan pergerakan mata yang tidak cepat atau  Non Rapid Eye Movement (NREM). Tidur diawali dengan fase NREM yang terdiri dari empat stadium, yaitu tidur stadium satu, tidur stadium dua, tidur stadium tiga dan tidur stadium empat, lalu diikuti oleh fase REM. Fase NREM dan REM terjadi secara bergantian sekitar 4-6 siklus dalam semalam. Apabila seseorang kurang cukup mengalami REM, maka esok harinya ia akan menunjukkan kecenderungan untuk menjadi hiperaktif, kurang dapat mengendalikan emosinya dan nafsu makan bertambah. Sedangkan  jika NREM kurang cukup, keadaan fisik menjadi kurang gesit. Siklus tidur normal merupakan salah satu dari irama sirkadian yang

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dipengaruhi oleh aktivitas neurotransmitter seperti sistem serotoninergik, noradrenergik, kolinergik, histaminergik. a.

Sistem Serotoninergik Hasil

serotoninergik

sangat

dipengaruhi

oleh

hasil

metabolisme asam amino triptofan. Dengan bertambahnya jumlah triptofan, maka jumlah serotonin yang terbentuk juga meningkat akan menyebabkan keadaan mengantuk/ tidur. Bila serotonin dalam triptofan terhambat pembentukannya, maka terjadi keadaan tidak bisa tidur/ jaga. Menurut beberapa peneliti lokasi yang terbanyak sistem serotoninergik ini terletak pada nucleus raphe dorsalis di batang otak, yang mana terdapat hubungan aktivitas serotonis di nucleus raphe dorsalis dengan tidur REM.  b.

Sistem Adrenergik  Neuron-neuron yang terbanyak mengandung norepinefrin terletak di badan sel nucleus cereleus di batang otak. Kerusakan sel neuron pada lokus cereleus sangat mempengaruhi penurunan atau hilangnya REM Stimulating Hormon (TSH), Lituenizing Hormon (LH). Hormon-hormon ini masing-masing disekresi secara teratur oleh kelenjar hipofisis anterior melalui jalur hipotalamus. Sistem ini secara

teratur

norepinefirn,

mempengaruhi

dopamine,

pengeluaran

serotonin

yang

neurotransmitter

bertugas

mengatur

mekanisme tidur dan bangun tidur. Obat-obatan yang mempengaruhi  peningkatan aktivitas neuron noradrenergik akan menyebabkan

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 pengeluaran kolinergik dari lokus sereleus maka tampak gangguan  pada fase awal dan penurunan REM. d.

Sistem Histaminergik Pengaruh histamin sangat sedikit mempengaruhi tidur.

e.

Sistem Hormon Siklus tidur dipengaruhi oleh beberapa hormon seperti Adrenal Corticotropin Hormone (ACTH), Growth Hormon (GH), Tyroid Stimulating Hormon (TSH), Lituenizing Hormon (LH). Hormon-hormon ini masing-masing disekresi secara teratur oleh kelenjar hipofisis anterior melalui jalur hipotalamus. Sistem ini secara teratur mempengaruhi pengeluaran neurotransmitter norepinefirn, dopamine, serotonin yang bertugas mengatur mekanisme tidur dan  bangun.

4. Apa yang menyebabkan menyebabkan terjadinya gangguan tidur? Jawab :

a. Stres Kekhawatiran tentang pekerjaan, kesehatan sekolah, atau keluarga dapat membuat pikiran menjadi aktif di malam hari, sehingga sulit untuk tidur. Peristiwa kehidupan yang penuh stres, seperti kematian atau penyakit dari orang yang dicintai, perceraian atau kehilangan  pekerjaan, dapat menyebabkan insomnia.

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d. Kafein, nikotin dan alkohol Kopi, teh, cola dan minuman yang mengandung kafein adalah stimulan yang terkenal. Nikotin merupakan stimulan yang dapat menyebabkan insomnia. Alkohol adalah obat penenang yang dapat membantu seseorang jatuh tertidur, tetapi mencegah tahap lebih dalam tidur dan sering menyebabkan terbangun di tengah malam. e. Kondisi Medis Jika seseorang memiliki gejala nyeri kronis, kesulitan bernapas dan sering buang air kecil, kemungkinan mereka untuk mengalami insomnia lebih besar dibandingkan mereka yang tanpa gejala tersebut. Kondisi ini dikaitkan dengan insomnia akibat artritis, kanker, gagal  jantung, penyakit paru-paru, gastroesophageal reflux disease (GERD), stroke, penyakit Parkinson dan penyakit Alzheimer. f.

Perubahan lingkungan atau jadwal kerja. Kelelahan akibat perjalanan jauh atau pergeseran waktu kerja dapat menyebabkan terganggunya irama sirkadian tubuh, sehingga sulit untuk tidur. Ritme sirkadian bertindak sebagai jam internal, mengatur siklus tidur-bangun, metabolisme, dan suhu tubuh.

g. 'Belajar' insomnia. Hal ini dapat terjadi ketika Anda khawatir berlebihan tentang tidak  bisa tidur t idur dengan baik dan berusaha terlalu te rlalu keras untuk jatuh tertidur. Kebanyakan orang dengan kondisi ini tidur lebih baik ketika mereka  berada jauh dari lingkungan l ingkungan tidur yang biasa atau at au ketika mereka tidak

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5. Bagaimana hubungan gangguan tidur dan perubahan perilaku sesuai dengan skenario? Jawab :

Tidur merupakan suatu proses aktif, bukan sekedar hilangnya keadaan terjaga. Tingkat aktivitas otak keseluruhan tidak berkurang selama tidur. Selama tahap-tahap tertentu tidur, penyerapan oksigen oleh otak bahkan meningkat melebihi tingkta normal sewaktu terjaga. Pada orang normal, gangguan tidur yang berkepanjangan akan mengakibatkan perubahan-perunahan pada siklus tidur biologisnya, menurunnya daya tahan tubuh serta menurunkan prestasi kerja, mudah tersinggung, depresi, kurang konsentrasi, kelelahan, yang pada akhirnya akan mempengaruhi keselamatan pada diri sendiri maupun orang lain. Gangguan tidur yang paling sering dialami masyarakat, seperti insomnia, narkolepsi, hipersomnia, dan obstruksi henti napas saat tidur. 1. Sakit kepala

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2. Mudah lelah & Energi berkurang

Kelelahan yang dirasakan seseorang dapat pula mempengaruhi kualitas tidur seseorang. Kelelahan yang berlebihan akan menyebabkan  periode tidur REM ( Rapid Eye Movement ) lebih pendek sehingga sulit memulai tidur. Kelelahan karena faktor psikologis seperti cemas, stres, dan depresi juga akan menyebabkan gangguan pada frekuensi tidur. Hal ini disebabkan karena kondisi cemas akan meningkatkan hormon norepinefrin darah melalui sistem saraf simpatis dimana zat ini yang akan mengurangi atau mengganggu tahap 4 REM ( Rapid ( Rapid Eye Movement ) dan NREM ( Non Rapid Eye Movement ), ), yaitu dimana seseorang tidur dalam keadaan rileks dan sulit dibangunkan tetapi karena terganggu maka seseorang akan sukar memulai tidur dan merasa tidak rileks (cemas, gelisah, stress, depresi).

3. Sulit konsentrasi & Kurang minat pada aktivitas

Dampak fisiologis dan psikologis yang muncul akibat buruknya kualitas tidur meliputi penurunan aktivitas sehari-hari, kelelahan respon

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memori aktif lebih rentan terhadap kurangnya tidur. Waktu tidur yang terbagi-bagi memiliki hubungan dengan pengurangan besar aktivitas kortikotalamik yang menghubungkan proses kesiagaan, atensi, dan fungsi kognitif di area prefrontal otak. Lobus frontal serebri juga berkaitan dengan gangguan tidur, yang mengalami kesulitan dalam memikirkan kata-kata imajinatif dan tidak mampu memfokuskan perhatian sehinga mengurangi kecepatan dan efisiensi kerja.

6. Bagaimana langkah-langkah diagnosis gangguan tidur? Jawab :

Untuk mendiagnosis pasien psikiatri dilakukan dengan 2 jenis anamnesi

yaitu

alloanamnesis

dan

autoanamnesis.

Alloanamnesis

merupakan anamnesis yang di dapat dari keluarga pasien tentang keluhan yang dirasakan pasien tersebut. Sedangkan autoanamnesis ialah anamnesis yang didapat dari pasien itu sendiri.

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Teknik umum pemeriksaan psikiatri, yaitu: 1. Bina rapport sejak awal 2. Tentukan keluhan utama 3. Gunakan keluhan utama untuk DD (Differential Diagnosa) 4. Singkirkan DD dengan pertanyaan fokus dan lebih ri nci 5. Lanjutkan jawaban pasien bila ada jawaban yang kurang jelas (samarsamar) 6. Biarkan pasien bicara bebas untuk mengetahui proses pikir 7. Gunakan campuran pertanyaan terbuka dan tertutup 8. Jangan takut bertanya hal yang sulit atau mungkin membuat pasien malu 9. Tanya tentang ide suicide 10. Berikan kesempatan pasien bertanya pada akhir wawancara

Setelah melakukan anamnesis, diagnosis ditegakkan berdasarkan  pengelompokan gejala klinik yang teramati. t eramati. Diagnosis deskriptif (dengan

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 presepsitentang diri dan lingkungan ( yang akan ditampilkan dalam  pola interaksi dengan orang lain) Contoh : gangguan kepribadian anankastik segala sesuatu yang dilihat harus sempurna, orang lain harus mengikuti perkataanya sehingga seringkali menimbulkan kekecewaan pada dirinya, sering terdapat suatu yang mengakibatkan obsesif kompulsif. 3. Aksis III: Penyakit Fisik Penyakit

atau

kondisi

fisik,

khususnya

yang

perlu

diperhatikan pada tatalaksanaan atau menjadi penyebab munculnya gangguan yang dituliskan di aksis I. 4. Aksis IV: Stresor Psikososial Merukapan stressor psikososial yaitu semua peristiwa yang yang mencetuskan gangguan yang dituliskan di aksis I. Contoh

:

Hubungan

antara

individu

meninggal). 5. Aksis V: Fungsi Penyesuaian Fungsi penyesuaian yang dinilai dari:

(bercerai,

ditinggal

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2.

Persepsi : a. Halusinasi Dapat berupa halusinasi auditorik, visual, gustatorik, taktil, olfaktorik,

kinestetik,

viseral,

hipnagonik,

histerik

dan

formicatioon. Tanyakan apakah pasien mendengar suara orang saat tidak ada orang disekitar, apakah suara tersebut datang dari luar atau didalam kepala, apakah ada halusinasi perintah dan apa reaksi pasien atas halusinasi tersebut.  b. Ilusi Merupakan penilaian yang salah tentang pencerapan yang sungguh terjadi.

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C. Pemeriksaan Status Mental

Pemeriksaan status mental merupakan bagian dari pengkajian klinis yang medeskripsikan keseluruhan observasi yang dilakukan oleh  pemeriksaan dan kesan didapatkan dari pasien psikiatri saat dilakukan wawancara. Walaupun riwayat pasien tetap stabil, status mental pasien dapat berubah setiap hari atau setiap jam. Pemeriksaan status mental adalah gambaran penampilan pasien, cara bicara, tindakan, pikiran selama wawancara. Bahkan bila pasien membisu, inkoheren, atau menolak  jawaban pertanyaan, dokter dapat memperoleh segudang informasi  berdasarkan pengamataan yang cermat.

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c. Daya Ingat (segera, janga pendek, jangka menengah, jangka  panjang) d. Konsentrasi dan perhatian e. Kemampuan membaca dan menulis f. Kemampuan Visuospasial 7. Pengendalian Impuls 8. Daya Nilai dan Tilikan a. Daya nilai sosial  b. Uji daya nilai c. Penilaian Realita d. Tilikan

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2. Uji perangsangan hormon pelepas tiroid (TRH) Indikasikan untuk pasien dengan hasil uji tiroid yang berada di  perbatasan abnormal yang mengisyaratkan adanya hipotiroidisme subklinis, yang mungkin menyebabkan depresi klinis. Uji ini juga dilakukan pada pasien dengan kemungkinan hipotiroidisme yang terinduksi litium. l itium. Prosedur ini membutuhkan injeksi TRH 500 mg intravena (IV), yang menghasilkan peningkatan tajam TSH serum bila diukur dalam 15, 30, 60, dan 90 menit. Peningkatan TSH serum dari 5 sampai 25 nIU/ml di atas nilai dasar dianggap normal. Peningkatan kurang dari 7 pilU/ml dianggap respons

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merupakan indikasi

untuk menghentikan pengobatan antidepresan

karena DST dapat menjadi normal sebelum depresi sembuh. Reliabilitasi : Masalah yang terkait dengan DST mencakup berbagai laporan mengenai sensitivitas dan spesifisitasnya.Hasil positif palsu dan negatifpalsu sering dijumpai. Sensitivitas DST dianggap sebesar 45  persen pada gangguan depresif mayor dan 70 persen pada episode depresi mayor dengan ciri psikotik. Spesifisitasnya 90 persen dibanding kontrol dan 77 persen bila dibandingkan dengan diagnosis psikiatri lain. Sejumlah bukti mengisyaratkan bahwa pasien dengan hasil DST positif

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Katekolamin Kadar metabolit serotonin asam 5-hidroksiindolasetat (5-HIAA) meningkat pada urine pasien dengan tumor karsinoid. Peningkatan kadar kadang-kadang terlihat pada pasien yang menjalani peng-obatan

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kreatinin 2-jam dan, pada akhirnya, bersihan kreatinin 24-jam. Tabel 4-2 merangkum pemeriksaan laboratorium lain untuk pasien yang mengonsumsi litium. 6. Uji Fungsi Hati

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campuran) yang terjadi secara bersamaan, akan tetapi gejala skizofrenia lebih dominan. b. Etiologi

Sampai sekarang etiologinya belum jelas, tetapi beberapa  pakar

mengatakan

bahwa

ada

kaitannya

dengan

faktor

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hal-hal yang biasanya dilakukan, merasa tidak berharga/ tidak punya harapan/ merasa bersalah. sulit konsentrasi &  berpikir, dan memikirkan kematian/ bunuh diri 3. Gangguan Skizoafektif Tipe Campuran Gangguan dengan gejala-gejala skizofrenia ada

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 b.

Laboratorium: kadar lithium plasma, GDS, fungsi hati & ginjal

c.

Radiologi: CT-Scan kepala untuk menyingkirkan kelainan vaskuler

d.

Pemeriksaan EEG ( Electro Encephalography) Encephalography) untuk

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