Zullies Ikawati's Lecture Notes SKIZOPRENIA 10/24/2017 Zullies Ikawati's Lecture Notes

Epidemiologi dan etiologi penyakit Prevalensi penderita skizoprenia di dunia sekitar 0,2 – 2 % populasi Mula terjadinya biasanya pada masa akhir remaja atau awal dewasa, jarang terjadi pada sebelum remaja atau setelah umur 40 tahun Angka kejadian pada wanita sama dengan pria, tetapi onset pada pria umumnya lebih awal (♂: 15-24 th; ♀: 25-35 th) lebih banyak gangguan kognitif dan outcome yang lebih jelek daripada wanita Prevalensinya 8 x lebih besar pada tingkat sosial ekonomi rendah dari pada tinggi Etiologi : faktor genetik (abnormalitas fungsi otak) dan lingkungan Resiko kejadian pada populasi = 1 %, resiko pada keluarga dekat (first-degree relatives) = 10 % 10/24/2017 Zullies Ikawati's Lecture Notes

Zullies Ikawati's Lecture Notes 10/24/2017 Zullies Ikawati's Lecture Notes

Zullies Ikawati's Lecture Notes Takrif dan pengertian Istilah Skizoprenia diciptakan oleh Bleuler (psikiater dari Swiss)  dari bahasa Yunani skhizo = split / membelah, dan phren = mind / pikiran  berarti : terbelahnya/ terpisahnya antara emosi dan pikiran/intelektual (people with schizophrenia are split off from reality and can’t distinguish what is real from what is not real) Merupakan penyakit psikiatrik kronik pada pikiran manusia  mempengaruhi seseorang sehingga mengganggu hubungan antarpersonal dan kemampuan untuk menjalani kehidupan sosial 10/24/2017 Zullies Ikawati's Lecture Notes

Zullies Ikawati's Lecture Notes Patofisiologi Patofisiologi skizoprenia melibatkan system dopaminergik dan serotonergik (more recently : glutamat) Hipotesis/teori tentang patofisiologi skizoprenia : Pada pasien skizoprenia terjadi hiperreaktivitas sistem dopaminergik Hiperdopaminergia pada sistem mesolimbik  berkaitan dengan gejala positif Hipodopaminergia pada sistem mesocortis dan nigrostriatal  bertanggungjawab thd gejala negatif dan gejala ekstrapiramidal 10/24/2017 Zullies Ikawati's Lecture Notes

Jalur dopaminergik saraf 1. Jalur nigrostriatal: dari substantia nigra ke basal ganglia  fungsi gerakan, EPS 2. jalur mesolimbik : dari tegmental area menuju ke sistem limbik  memori, sikap, kesadaran, proses stimulus 3. jalur mesocortical : dari tegmental area menuju ke frontal cortex  kognisi, fungsi sosial, komunikasi, respons terhadap stress 4. jalur tuberoinfendibular: dari hipotalamus ke kelenjar pituitary  pelepasan prolaktin 10/24/2017 Zullies Ikawati's Lecture Notes

Zullies Ikawati's Lecture Notes 10/24/2017 Zullies Ikawati's Lecture Notes

Zullies Ikawati's Lecture Notes In human anatomy, the extrapyramidal system is a neural network located in the brain that is part of the motor system involved in the coordination of movement. The system is called "extrapyramidal" to distinguish it from the tracts of the motor cortex that reach their targets by traveling through the "pyramids" of the medulla. The pyramidal pathways (corticospinal and some corticobulbar tracts) may directly innervate motor neurons of the spinal cord or brainstem (anterior horn cells or certain cranial nerve nuclei), whereas the extrapyramidal system centers around the modulation and regulation (indirect control) of anterior horn cells. 10/24/2017 Zullies Ikawati's Lecture Notes

Zullies Ikawati's Lecture Notes serotonergic neurons from the dorsal and median raphe nuclei project to dopaminergic cell bodies within the VTA and SN of the midbrain. Serotonergic neurons primarily from the dorsal raphe project to the terminal fields of the striatum, nucleus accumbens, and cortex. Serotonergic neurons have been reported to directly terminate on dopaminergic cell bodies and exert an inhibitory influence on mesolimbic and nigrostriatal dopamine activity through 5-HT2A receptors 10/24/2017 Zullies Ikawati's Lecture Notes

Zullies Ikawati's Lecture Notes reductions in serotonin activity are associated with enhancements in dopamine activity 10/24/2017 Zullies Ikawati's Lecture Notes

Zullies Ikawati's Lecture Notes lanjutan Reseptor dopamine yang terlibat adalah reseptor dopamine-2 (D2)  dijumpai peningkatan densitas reseptor D2 pada jaringan otak pasien skizoprenia Peningkatan aktivitas sistem dopaminergik pada sistem mesolimbik  bertanggungjawab terhadap gejala positif Peningkatan aktivitas serotonergik  menurunkan aktivitas dopaminergik pada sistem mesocortis  bertanggung-jawab terhadap gejala negatif 10/24/2017 Zullies Ikawati's Lecture Notes

Zullies Ikawati's Lecture Notes More recent data implicate dysfunctions in glutamatergic neurotransmission in the pathophysiology of psychosis  deficiency of glutamate lead to psychotic effects 10/24/2017 Zullies Ikawati's Lecture Notes

Zullies Ikawati's Lecture Notes Gejala dan tanda gambaran klinis skizoprenia sgt bervariasi tidak ada stereotip yg pasti skizoprenia bukan “split personality”  tetapi gangguan pikiran yang kronis dan mempengaruhi hubungan interpersonal dan kemampuan untuk berfungsi sosial sehari-hari  pada fase normal, pasien memiliki kontrol yang baik terhadap pikiran, perasaan, tindakannya. episode psikotik yang pertama kali mungkin terjadi secara tiba-tiba, atau biasanya diawali dengan kelakuan yang menarik diri, pencuriga, dan aneh pada episode akut, pasien kehilangan kontak dengan realitas, dalam hal ini otak menciptakan realitas palsu 10/24/2017 Zullies Ikawati's Lecture Notes

From memoir of Prof. Elyn Sacs (Majalah Time, 27 Agst 2007) When was your first episode? At seven or eight. I asked my dad, 'can't we go to the cabana?' He kind of snapped at me, 'I already said no, and the weather's not great. I need to go back to work.' And at that moment, I disappointed my dad. It felt like falling apart, my self losing coherence. Imagine a sand castle with all the sand sliding away in the receding surf. So in the end, there's no center to take things in and process them and view the world. That was the first kind of scary, weird thing. Even more alarming, when I was 16 or 17, I suddenly, having just read Sylvia Plath and identifying with her, got up in the middle of the day [at school] and started walking home several miles away, something I'd never done before. I was a good girl — I never skipped school. And as I was walking, the houses got very ominous and foreboding, and I started to think that they were sending me messages. 'Look! See! You must see! You are bad! You are evil!' I didn't hear it as voices; they were thoughts, but I thought they were thoughts put in my head by the houses. It was very scary. 10/24/2017 Zullies Ikawati's Lecture Notes

Zullies Ikawati's Lecture Notes Diagnostic and Statistical Manual of Mental Disorders edisi 4 (DSM-IV) membagi gejala skizoprenia menjadi 2 katagori  berkembang menjadi 3 kategori (APA) Gejala positif Gejala negatif Gejala kognisi Delusion (khayalan) Alogia (Kehilangan kemampuan berpikir atau bicara) Gangguan perhatian Halusinasi Perasaan/emosi menjadi tumpul Gangguan ingatan Perilaku aneh, tidak terorganisir Avolition (Kehilangan motivasi) Gangguan fungsi melakukan pekerjaan tertentu Bicara tidak teratur, topik melompat-lompat tidak saling berhubungan Anhedonia/asosiality (kurangnya kemampuan untuk merasakan kesenangan, mengisolasi diri dari kehidupan sosial Ilusi, pencuriga Tidak mampu berkonsentrasi 10/24/2017 Zullies Ikawati's Lecture Notes

Zullies Ikawati's Lecture Notes 10/24/2017 Zullies Ikawati's Lecture Notes

Zullies Ikawati's Lecture Notes Diagnosis Pasien didiagnosis menderita skizoprenia jika terdapat 2 atau lebih tanda-tanda seperti : delusi halusinasi disorganized speech perilaku katatonik (aktivitas motorik berlebihan) gejala negatif secara terus menerus sedikitnya dalam waktu enam bulan, dengan sedikitnya ada satu bulan di mana pasien menunjukkan gejala-gejala tersebut secara intensif Note : 6 bln meliputi gejala prodromal dan residual 10/24/2017 Zullies Ikawati's Lecture Notes

Zullies Ikawati's Lecture Notes Prognosis Prognosis cukup baik jika : onset lebih lambat, pemicunya diketahui, sejarah pre-morbid bagus, dan ada dukungan keluarga  20-30% mungkin bisa kembali normal Kurang lebih 20-30 % mungkin akan mengalami gejala sedang 40 – 60% mungkin tidak akan kembali normal seumur hidupnya 10/24/2017 Zullies Ikawati's Lecture Notes

Zullies Ikawati's Lecture Notes Sasaran terapi Sasaran terapi: bervariasi, berdasarkan fase dan keparahan penyakit Pada fase akut : mengurangi atau menghilangkan gejala psikotik dan meningkatkan fungsi Pada fase stabilisasi: mengurangi resiko kekambuhan dan meningkatkan adaptasi pasien terhadap kehidupan dalam masyarakat 10/24/2017 Zullies Ikawati's Lecture Notes

Zullies Ikawati's Lecture Notes Strategi terapi Non-farmakologi : program rehabilitasi : living skills, social skills, basic education, work program,supported housing Psikoterapi : terapi tambahan, terutama jika pasien sudah berespon thd obat Family education Farmakologi : menggunakan obat antipsikotik 10/24/2017 Zullies Ikawati's Lecture Notes

Zullies Ikawati's Lecture Notes Terapi Farmakologi Menggunakan obat-obat antipsikotik untuk memodulasi neurotransmiter yang terlibat Antipsikotik Tipikal/FGA Atipikal/SGA Generasi lama Memblok reseptor dopamin D2 Efek samping EPS besar Efektif untuk mengatasi gejala positif Generasi lebih baru (th 1990an) Memblok reseptor 5-HT2, efek blokade dopamin rendah Efek samping EPS lebih kecil Efektif untuk mengatasi gejala baik positif maupun negatif 10/24/2017 Zullies Ikawati's Lecture Notes

Antipsikotik tipikal (FGA) Klorpromazin Tioridazin Mesoridazin Flufenazin Perfenazin Thiotixene Haloperidol Loxapin Molindon Low potency High potency Pada dasarnya potensi tidak berhubungan dengan efektifitas obat  hanya menunjukkan miligram equivalency (contoh : haloperidol 15 mg equivalent dengan klorpromasin 750 mg)  jika digunakan dalam dosis yang ekuipoten semua antipsikotik tipikal sama efikasinya 10/24/2017 Zullies Ikawati's Lecture Notes

Antipsikotik atipikal (SGA) Clozapin Risperidon Olanzapin Quetiapin Ziprasidon Aripiprazol Antagonis reseptor 5-HT, Blokade dopamin rendah terdapat hubungan kuat antara system dopaminergik dan serotonergik  serotonin memodulasi fungsi dopamine (reductions in serotonin activity are associated with enhancements in dopamine activity) Saat ini lebih banyak digunakan sebagai “drug of choice” karena relatif lebih aman dari efek samping ekstrapiramidal 10/24/2017 Zullies Ikawati's Lecture Notes

Terapi pada episode akut skizoprenia : Tujuan terapi 7 hari pertama : mengurangi agitasi, hostility, agresi, anxiety jika seorang pasien terkena serangan psikotik akut, lebih baik diatasi dengan “meng-imobilisasi” pasien dulu dan mengajaknya bicara, kemudian diberi benzodiazepine untuk penenang dan atau suatu obat antipsikotik benzodiazepine (exp: lorazepam 2 mg i.m setiap 30 menit) terbukti efektif mengurangi agitasi  shg mengurangi dosis antipsikotik yang dibutuhkan  mengurangi efek samping Jika dibutuhkan antipsikosis utk agitasi yang berat  obat potensi tinggi bisa digunakan, exp: haloperidol 2-5 mg IM setiap 60 min Selanjutnya dapat digunakan antipsikotik lain sesuai algoritma 10/24/2017 Zullies Ikawati's Lecture Notes

Zullies Ikawati's Lecture Notes Terapi stabilisasi Terapi minggu ke 2-3  terapi stabilisasi  tujuannya: meningkatkan sosialisasi dan perbaikan kebiasaan (self-care habits) dan perasaan Mungkin perlu waktu 6-8 minggu utk mendapat respon yang diharapkan, pada pasien kronis  mungkin butuh waktu 3-6 bulan Pengobatan : menggunakan antipsikotik atipikal (if any); jika menggunakan obat tipikal: dosis yang ekuivalen dengan klorpromasin 300-1000 mg dapat digunakan Terapi tidak bisa menyembuhkan, hanya mengurangi gejala 10/24/2017 Zullies Ikawati's Lecture Notes

Zullies Ikawati's Lecture Notes Terapi pemeliharaan Tujuan : mencegah kekambuhan harus diberikan sedikitnya sampai setahun sejak sembuh dari episode akut bahkan untuk bisa lebih berhasil  perlu terapi selama sedikitnya 5 tahun, kemudian dosis pada diturunkan perlahan-lahan terapi pemeliharaan dapat diberikan dalam dosis setengah dari dosis akut bagi pasien yang kepatuhannya rendah  ada obat yang dibuat dalam formulasi depot  contoh : flufenazin dekanoat atau haloperidol dekanoat  dapat diberikan setiap 2 -4 minggu sekali secara i.m.  tetapi formulasi depot ini hanya dapat diberikan jika pasien telah memiliki dosis efektif p.o yang stabil Recently : Risperidon long acting dg dosis 25-50 mg IM every 2 weeks 10/24/2017 Zullies Ikawati's Lecture Notes

Penatalaksanaan pasien yang resisten terhadap pengobatan Satu-satunya obat yang terbukti superior dalam uji klinik pada pasien resisten adalah Clozapin Namun karena CLZ memiliki efek samping hipotensi ortostatik, dosis harus dititrasi Obat penguat dapat diberikan jika pasien tidak berespon baik  contoh: Li, Carbamazepin, asam valproat 10/24/2017 Zullies Ikawati's Lecture Notes

Algoritma terapi skizoprenia TIMA Algoritma terapi skizoprenia Tahap 1: Coba SGA tunggal: Aripiprazol, olanzapin, quetiapin, risperidon, atau ziprasidon Serangan pertama atau belum pernah menggunakan SGA sebelumnya max 12 minggu Respon parsial atau tidak ada Tahap 2: Coba SGA tunggal yang lain selain yang dipakai pada tahap 1 max 12 minggu Respon parsial atau tidak ada Respon parsial atau tidak ada 6 bulan Tahap 3 Coba FGA atau SGA yg lain Tahap 2A Coba FGA atau SGA yg lain Respon parsial atau tidak ada 10/24/2017 Zullies Ikawati's Lecture Notes

Respon parsial atau tidak ada Tahap 4 Klozapin Menolak klozapin tidak ada respon Tahap 5 Coba satu obat FGA atau SGA yg belum dicoba tidak ada respon Tahap 6 Terapi kombinasi SGA + FGA, kombinasi SGA, (FGA atau SGA) + ECT, (FGA atau SGA) + agen lain 10/24/2017 Zullies Ikawati's Lecture Notes

Algoritma tatalaksana terapi Tidak ada riwayat Kegagalan terapi AT Ada riwayat Kegagalan terapi AT Olanzapin or Quetiapin or Risperidon Olanzapin or Quetiapin or Risperidon Gunakan salah satu Gunakan salah satu Stage 1 Tidak ada respon Tidak ada respon Tidak patuh Tidak patuh Haloperidol dekanoat atau flufenazin dekanoat Stage 2 Gunakan yang lain Gunakan yang lain Tidak ada respon Tidak ada respon Tidak ada respon Stage 3 Gunakan yang lain Gunakan yang lain Gunakan yang lain Tidak ada respon Tidak ada respon Tidak ada respon Stage 4 Gunakan AP tipikal Tidak ada respon 10/24/2017 Zullies Ikawati's Lecture Notes Cont’d Stage 5 Clozapin

Kombinasi Atipikal+tipikal, atau kombinasi tipikal, lanjutan Clozapin Stage 5 Respon parsial Stage 5a Clozapin + obat pendukung (AP tipikal/atipikal, mood stabilizer, ECT, antidepresan Tidak ada respon atau menolak klozapin Tidak ada respon Stage 5b Kombinasi Atipikal+tipikal, atau kombinasi tipikal, atau kombinasi atipikal, atau atipikal + ECT 10/24/2017 Zullies Ikawati's Lecture Notes

Zullies Ikawati's Lecture Notes Efek samping relatif Obat sedasi ekstrapiramidal antikolinergik ortostatik Klorpromazin ++++ +++ Flufenazin + Haloperidol Loksapin ++ Perfenazin Tioridazin Tiotiksen Molindon Klozapin  Olanzapin Quetiapin Risperidon Ziprasidon 10/24/2017 Zullies Ikawati's Lecture Notes

Zullies Ikawati's Lecture Notes 10/24/2017 Zullies Ikawati's Lecture Notes

Rentang dosis oral efektif dan potensi anti psikotik Obat Dosis akut (mg/hari) Dosis pemeliharaan (mg/hari) Potensi Klorpromasin 400 – 1000 100 – 300 100 Tioridazin 400 – 800 100 – 200 Flufenazin 10 – 60 3 – 20 2 Perfenazin 8 – 64 4 – 32 8 Trifluoperazin 20 – 80 5 – 20 5 Tiotiksen 5 – 30 4 Haloperidol Loxapin 40 – 160 10 Molindon 50 – 200 20 – 100 Klozapin 300 – 600 150 – 400 - Risperidon 4 – 6 2 – 4 Olanzapin 10 – 20 5 – 50 Quetiapin 150 – 300 10/24/2017 Zullies Ikawati's Lecture Notes

Antipsikotik yang beredar di Indonesia (ISO 2004, IONI 2000) Klorpromazin (generik, Meprosetil, Largactil, Largazine, Promactil) Haloperidol (Lodomer, Govotil, Halonace, Haldol, Seradol, Serenace) Flufenazin (Anatensol) Perfenazin (generik, Trilafon) Proklorperazin (Stemetil) Tioridazin (Melleril) Trifluoperazin (generik, Stelazine, Trizine) Levomepromazin (Nozinan) Flufenazin dekanoat (Modecate) Haloperidol dekanoat (Haldol decanoas) Risperidon (Persidal, Rizodal, Zofredal) Klozapin (Clozaril) Quetiapin Olanzapin 10/24/2017 Zullies Ikawati's Lecture Notes

Zullies Ikawati's Lecture Notes Masalah dalam penggunaan obat antipsikotik : ketidakpatuhan akibat efek samping obat efek samping ekstrapiramidal  dijumpai pada obat antipsikotik tipikal efek antikolinergik (mulut kering, pandangan kabur, konstipasi, retensi urin, penurunan memori)  pada antipsikotik potensi rendah (exp: klorpromazin) tardive dyskinesia  gerakan yg tidak terkontrol, terutama pada mulut, lidah efek pada kardiovaskuler (hipotensi ortostatik)  pada obat tipikal dan atipikal efek pada fungsi seksual dan endokrin kejang  potensi tertinggi pada pemakaian klorpromazin atau klozapin 10/24/2017 Zullies Ikawati's Lecture Notes

Efek samping utama ? Gejala ekstra piramidal dystonic reaction (kekejangan otot yang nyeri) - banyak dijumpai pada obat antipsikotik potensi tinggi - diatasi dengan obat antikolinergik (benztropin, THF, atau difenhidramin) Pseudoparkinsonism - adanya blockade dopaminergik di striatum  muncul gejala mirip Parkinson - diatasi dengan antikolinergik (benztropin) atau amantadin akathisia ( tidak bisa duduk tenang, dan gerakan-gerakan yang tidak bisa berhenti) - paling tidak responsive terhadap terapi  turunkan dosis, atau - diatasi dengan propanolol atau benzodiazepine (lorazepam, klonazepam) 10/24/2017 Zullies Ikawati's Lecture Notes

Zullies Ikawati's Lecture Notes 10/24/2017 Zullies Ikawati's Lecture Notes

Zullies Ikawati's Lecture Notes Prevention ? Recent study : schizophrenia is due to a genetic predisposition and environmental stressors early in a child's development (during pregnancy and birth, and/or early childhood) which lead to subtle alterations in the brain that make a person susceptible to developing schizophrenia. Additional environmental factors and stresses later in life (during childhood, adolescence and young adulthood) can either damage the already vulnerable brain further or lessen the expression of neurodevelopmental defects and decrease the risk of schizophrenia There is no specific amount of genetic or environmental input that has been identified that will ensure someone will or will not develop schizophrenia so it is never to late or too early to begin planning for your mental health and that of your children 10/24/2017 Zullies Ikawati's Lecture Notes

Evaluasi outcome terapi Pemantauan dapat dilakukan dgn berbagai alat bantu, misal: Brief Psychiatric Rating Scale (BPRS), Positive and Negative Symptom Scale (PANSS), dll Pemantauan juga dilakukan terhadap ESO, spt: EPS (utama), weight gain, antikolinergik, hipotensi ortostatik, dll. Khusus utk clozapin : check WBC setiap minggu selama terapi. 10/24/2017 Zullies Ikawati's Lecture Notes

Agranulocytosis Monitoring Guidelines Check WBC before starting clozapine. Do not start the drug if the WBC is less than 3500/mm3. Teach patient to immediately report any sign of infection, such as sore throat, fever, weakness, lethargy. Measure WBC level every week during treatment and for 4 weeks after treatment ends. If laboratory results reveal a WBC of: < 2000/mm3 or an absolute neutrophil count (ANC) < 1000/mm3  stop clozapine, check WBC and differential daily, consider bone marrow aspiration and protective isolation. 2000 - 3000/mm3 or ANC is 1000-1500/mm3  stop clozapine, check WBC and differential daily, monitor for signs of infection; clozapine may be resumed if infection absent, WBC rises above 3000/mm3, and ANC above 1500 mm3, but continue checking WBC and differential twice weekly. 3000-3500/mm3, a drop of 3000/mm3 over 1-3 weeks, or immature forms, repeat WBC with a differential count. If the repeat WBC is still 3000-3500/mm3 and the ANC is more than 1500/mm3, repeat WBC with differential twice weekly until the count rises above 3500/mm3. 10/24/2017 Zullies Ikawati's Lecture Notes

Key points: Key points:Key skizoprenia adalah penyakit kronis yang memerlukan terapi pemeliharaan untuk mencegah kekambuhan perbedaan antara gejala negative dan positif mempengaruhi pemilihan obat, selain pertimbangan profil efek samping dan sejarah respon thd obat pada pengatasan episode akut, penggunaan kombinasi benzodiazepin dengan suatu obat antipsikotik yang tepat lebih baik daripada menggunakan antipsikotik dosis tinggi Tanpa pemeliharaan dengan obat, 70% pasien dapat kambuh dalam waktu satu tahun Terapi pemeliharaan yang terus menerus menggunakan antipsikotik dosis rendah diperlukan, karena terapi yang terputus-putus tidak dapat mencegah kekambuhan 10/24/2017 Zullies Ikawati's Lecture Notes

Zullies Ikawati's Lecture Notes lanjutan Efek samping gejala ekstra pyramidal dan tardive dyskinesia merupakan efek samping tersering dan serius dari obat antipsikotik dan merupakan penyebab utama ketidak patuhan pasien terhadap pengobatan Obat antipsikotik atipikal merupakan revolusi dalam pengobatan skizoprenia  th 1990, untuk pertama kalinya gejala negative dapat diobati secara efektif Risperidon, olanzapin, dan quetiapin merupakan pemula generasi obat atipikal  menjadi first line treatment untuk skizoprenia 10/24/2017 Zullies Ikawati's Lecture Notes

Selesaaai…

Dopamine pathways involved in schizophrenia Mesocortical system: Negative symptoms Nigrostriatal system: Extrapyramidal disorders Mesolimbic system: Positive symptoms Tuberoinfundibular System: Neuroendocrine symptoms Dopamine pathways involved in schizophrenia 10/24/2017 Zullies Ikawati's Lecture Notes

How to Lower Your Child's Risk for Schizophrenia Relationship Factors Build a relationship, or marry, a person with whom you can have a stable, loving and (mostly) low-stress relationship Make an extra effort to resolve the differences to both people's satisfaction. Learn conflict resolution skills Pre-Pregnancy Planning Begin prenatal planning at least three months prior to pregnancy Make Extra Effort to Maintain Low Levels of Physical, Social and Emotional Stress & Anxiety (worry) Immediately before, and During Pregnancy Take a multivitamin daily for 1 to 3 months prior to conception Make sure that any sexually transmitted diseases (eg. Herpes, Chlamydia, etc.) have been treated by a medical professional prior to pregnancy Make an extra effort to be at a healthy weight prior to pregnancy Make extra efforts to avoid alcohol and lead exposure prior to, and during Pregnancy Husbands should try to plan to have children when they are younger, rather than older Consider having a longer (greater than 27 months) interval between pregnancies, to maximize mental health of children 10/24/2017 Zullies Ikawati's Lecture Notes

Pregnancy Factors for Husband and Wife During pregnancy be sure to get enough of the key vitamins for the child's healthy brain development Do not smoke cigarettes or use other tobacco products during pregnancy Avoid all medications (unless doctor prescribed) during the pregnancy Avoid Dry Cleaning chemicals during the pregnancy (and keep young children away from recently dry cleaned clothes) It may be good for the baby's brain for the mother to continue moderate exercise after start of pregnancy Test for risk of RH blood incompatibility between mother and child during, or after, the pregnancy Consider taking extra precautions to avoid getting the flu, during flu season Eat a healthy diet with a lot of vegetables and the recommended amount of fish with omega 3 fatty acids Consider taking extra precautions to minimize risk of baby delivery complications Consider minimizing your exposure to cats during your pregnancy After Birth - Make Sure the Mental Health of the Mother is Good Breast feed the baby for at least 6 months, unless otherwise directed by a doctor Consider vitamin D supplementation during the first year of life for baby boys Consider having, and raising, your child outside of an urban environment 10/24/2017 Zullies Ikawati's Lecture Notes

Zullies Ikawati's Lecture Notes Childhood Factors Learn as much as you can about important new lessons that psychology and neuroscience research is teaching us about how to raise babies and children for maximum mental health During the first year of life, the baby should be held by a caring human for 4 hours or more a day Try to moderate the stress that children experience and help coach them on how to most effectively and positively deal with the stress they do experience Minimizing "Expressed Emotion" (yelling, shouting, arguing, or over-involvement & controlling behavior) Learn from the latest research into Child Development and Practice Sensitive, Nurturing, Low-stress Parenting Teach Children a Positive, Optimistic View on Life and life's events Encourage the development of good social skills for your children A family may want to work on providing an enriched educational, nutritional and social environment for their children If the Family Emmigrates to a different country, the family should make extra efforts to make sure that the child integrates well in the new environment and makes strong friendships Try to minimize traumatic events in a child's life Encourage the development of good "reality testing" skills 10/24/2017 Zullies Ikawati's Lecture Notes

Type skizoprenia (APA, 1994) Paranoid type The patient meets the basic criteria for Schizophrenia The patient is preoccupied with delusions or frequent auditory hallucinations. None of these symptoms is prominent: - Disorganized speech - Disorganized behavior - Inappropriate or flat affect - Catatonic behavior   Disorganized type All of these symptoms are prominent: - disorganized behavior - disorganized speech - affect that is flat or inappropriate The patient does not fulfill criteria for Catatonic Schizophrenia 10/24/2017 Zullies Ikawati's Lecture Notes

Zullies Ikawati's Lecture Notes Catatonic Type The patient meets the basic criteria for Schizophrenia At least 2 catatonic symptoms predominate: -Stupor or motor immobility (catalepsy or waxy flexibility) -Hyperactivity that has no apparent purpose and is not influenced by external stimuli -Mutism or marked negativism -Peculiar behavior such as posturing, stereotypies, mannerisms or grimacing -Echolalia or echopraxia   Coding Notes Negativism is demonstrated when the patient (1) refuses to follow all instructions without apparent motive or (2) maintains a rigid posture despite the examiner's physical attempts. Mannerisms are unnecessary movements that are part of goal-directed behavior, such as a flourish of the pen when signing a document). Stereotypies are behaviors that do not appear to be goal-directed, such as flashing a "Victory" sign with two upraised fingers every few seconds. Posturing means that the patient spontaneously poses or assumes a posture that is bizarre or inappropriate. 10/24/2017 Zullies Ikawati's Lecture Notes

Zullies Ikawati's Lecture Notes Undifferentiated Type The patient meets the basic criteria for Schizophrenia The patient does not meet criteria for Paranoid, Disorganized, or Catatonic types. Residual Type The patient at one time met criteria for Catatonic, Disorganized, Paranoid or Undifferentiated Schizophrenia. The patient no longer has pronounced catatonic behavior, delusions, hallucinations or disorganized speech or behavior. The patient is still ill, as indicated by either -negative symptoms such as flattened affect, reduced speech output or lack of volition, or -an attenuated form of at least 2 characteristic symptoms of schizophrenia, such as odd beliefs (related to delusions), distorted perceptions or illusions (hallucinations), odd speech (disorganized speech) or peculiarities of behavior (disorganized behavior). 10/24/2017 Zullies Ikawati's Lecture Notes