Substance Related Disorder.ppt

7/30/2019 Substance Related Disorder.ppt

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SUBSTANCE

RELATED DISORDER


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GANGGUAN MENTAL PERILAKUPENYALAHGUNAAN Zat

Tujuan :

Mampu diagnose klinisMampu terapi awal

Merujuk kasus emergency maupunnon emergency

Tugas Baca kaplan edisi 10


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Gangguan mental, perilaku akibat zat : Penyalahgunaan obat Sindroma ketergantungan Gangguan Psikotik Keadaan putus obat

Penyalahgunaan zat tidak menyebabkan ketergantungandiagnoses (F 55) : antidepresan (F 55,0),pencahar( F 55.1) ,aspirin, analgetika (F 55.2), antasida (F 55.3), vitamin (F55.4),

jamu( F 55.6).


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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.


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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)


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Komorbiditas ( diagnose ganda ) padapenyalahgunaan atau ketergantungan zat :

Gangguan kepribadian antisosial ditandai : kurangpuas dgn kehidupan , perilaku impulsif , isolasisosial.

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.


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Masalah ancamam penyebaran HIV/AID dapat

terjadi Injecting Drug User / IDU :

Menghisap opium->injeksi heroin / opiat lebihsering 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).


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Kepribadian dependent ditandai pengukuran rasakebahagian membutuhkan pengakuan dari oranglain ,sehingga tidak bisa mengambil sikap tegas ,kurang percaya diri.

Adanya masalah hubungan orang tua dengan anakyg disebabkan orang tua terlalu menuntut nilaitinggi membuat kebingungan peran anak.

Riwayat anak dengan gg pemusatan perhatian , ygsaat dewasa dapat menyebabkan ggpenyalahgunaan zat , dll.


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INTRODUCTION

Cover substance dependence and substance abuse with descriptionsof the clinical phenomena associated with the use of 11 designatedclasses 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 11designated classes, such as anabolic steroids and nitrous oxide


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TERMINOLOGY

Two concepts have been used to define aspects

of dependence: behavioral and physical

- behavioral dependence, substance-seekingactivities and related evidence of pathological

use patterns are emphasized

- physical dependencerefers to the physical

(physiological) effects of multiple episodes ofsubstance use


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Somewhat related to dependence are the

related words addiction and addict

- Addict has acquired a distinctive(tersendiri), unseemly,and pejorative connotation that ignores the concept of

substance abuse as a medical disorder

- Addictionhas also been trivialized in popularusage, 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 maybe found among all addictions, whether to substances or to

gambling, sex, stealing, or eating


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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


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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 problemexists, then they are responsible


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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


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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.

In definitions stressing physical dependence, ideas of tolerance or

withdrawal appear in the classification criteria


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DSM-IV-TR Criteria for Substance Intoxication

A. The development of a reversible substance-specific syndromedue 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 thecentral 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 andare not better accounted for by another mental disorder.


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DSM-IV-TR Criteria for Substance Abuse

A. A maladaptive pattern of substance use leading to clinically significant impairment ordistress, as manifested by one (or more) of the following, occurring within a 12-

month 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. recurr ent subs tance-related legal pro blems(e.g., arrests for substance-

related 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


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COURSE MODIFIERS FOR

SUSTANCE DEPENDENCE


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DSM-IV-TR Criteria for Substance DependenceA maladaptive pattern of substance use, leading to clinically significant impairment or distress, asmanifested 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 ordesired 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 apersistent 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)


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Cours e specif iers:

- Early Full Remission- Early Partial Remission- Sustained Full Remission

- Sustained Partial Remission- On Agonist Therapy-In a Controlled Environment

Specifyif: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)


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Early full remission

This sp ecif ier is us ed if , for at least 1 mon th, but for less th an

12 mon ths, no cr i ter ia for dependence or abus e 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 (bu t the ful l cr i ter ia for depend ence have not b een m et)


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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 of12 months o r 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


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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 prescribedagonist medication, and no criteria for dependence or abusehave 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


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In a controlled environment

- This specifier is used if the individual is in anenvironment where access to alcohol and

controlled substances is restricted, and no criteriafor dependence or abuse have been met for at

least the past month


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EPIDEMIOLOGY


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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 sufferingfrom a substance-related disorder. Of this group, about 15 million weredependent on, or abused, alcohol


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Dependence on, or abuse of, specific substances within the past year, 2004.

(From National Survey on Drug Use and Abuse, with permission


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Time Period

Lifetime Past Year Past Month

Age Category 2003 2004 2003 2004 2003 2004

TOTAL 46.4 45.8 14.7 14.5 8.2 7.9

12 12.2 11.2 6.2 6.7 2.7 2.8

13 18.7 18.4 11.9 11.6 4.9 4.6

14 26.3 25.2 18.7 17.8 8.5 9.0

15 34.2 34.7 25.2 24.6 13.3 12.7

16 43.8 42.5 33.2 31.0 18.6b 15.5

17 48.4 48.4 36.1 34.9 19.7 19.118 53.5 53.4 38.2 38.8 22.6 21.2

19 58.3 56.6 39.9 38.6 23.5 22.8

20 62.0 59.0 40.3 38.1 24.0 21.3

Illicit Drug Use in Lifetime, Past Year, and Past Month, by Detailed Age

Category: Percentages, 2003 and 2004


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21 61.6 62.3 35.0 36.6 20.7 21.7

22 64.0 62.9 33.5 35.1 19.6 20.5

23 63.4a 59.5 32.2a 28.3 18.0a 15.4

24 62.3 59.8 30.1 27.6 17.2 16.2

25 60.1 60.5 25.9 26.7 15.7 15.2

26-29 57.9 60.0 23.6 23.5 13.4 13.2

30-34 56.8 54.5 16.6 15.7 8.8 9.4

35-39 61.7 59.4 15.0 14.1 8.4 7.2

40-44 65.3 64.9 14.0 14.4 8.1 7.5

45-49 62.3 61.8 12.6 11.8 6.8 6.8

50-54 52.0 56.3 7.4 9.0 3.9 4.8

55-59 38.3 38.2 4.4 5.1 2.0 2.6

60-64 23.8 24.2 2.9 2.0 1.1 1.1

> 65 9.9 8.3 0.7 0.9 0.6 0.4

The rate for dependence or abuse was 1.3 percent at age 12, and ratesgenerally increased until the highest rate (25.4 percent) at age 21. Afterage 21, a general decline occurred with age. By age 65, only about 1

percent of persons have used an illicit substance


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ETIOLOGY


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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), adefense 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


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LEARNING AND CONDITIONING

Some drugs may sensitize neural systems to thereinforcing effects of the drug

Eventually, the paraphernalia (needles, bottles,

cigarette packs) and behaviors associated withsubstance use can become secondary reinforcers, aswell as cues(isyarat) signaling availability of thesubstance, and in their presence, craving or a desire toexperience the effects increases

Drug users respond to the drug-related stimuli withincreased activity in limbic regions, including theamygdala and the anterior cingulate


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GENETIC FACTOR Strong evidence from studies oftwins, 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.


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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


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This pathway is probably involved in the sensation ofreward 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 o f theop iates and the opio ids.

These pathways have collectively been called the

brain-reward circuitry


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SUBTANCES


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Alcohol use disorders are common lethal conditionsthat often masquerade(menyamarkan) as other

psychiatric syndromes

Alcohol intoxication can cause irritability, violent

behavior, feelings of d epression, and, in rareinstances, 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 canprecipitate a withdrawal syndrome usually marked by

insomnia, evidence of hyperactivity of the autonomic

nervous system, and feelings of anxiety

ALCOHOL RELATED DISORDER


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Alcohol Epidemiology

Condition Population (%)

Ever had a drink 90

Current drinker 60-70

Temporary problems 40+

Abusea Male: 10+

Female: 5+

Dependencea Male: 10

Female: 3-5

a

Twenty to 30 percent of psychiatric patients


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Etiology of alcohol related disorder Psychological Theories

use of alcohol to reduce tension , increase feel ings ofpower, and decrease the effects of ps ycholo gical pain

Psychodynamic TheoriesTo help them deal with self-pun it ive(menghu kum)

harsh superegos and to decrease unco nsciou s s tress levels

Classic psychoanalytical theory hypothesizes that at least

some alcoholic people may have become fixated at the oralstage of development and use alcohol to relieve their frustrations

by taking the substance by mouth


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Behavioral Theories

Drink again after the first experience with alcoholand to continue to imbibe(meminum) despite problems

Sociocultural Theories

Theorists hypothesize that ethnic groups lead toalcohol abuse and dependence

Genetic Theories

Evidence show that genetic lead to alcohol abuse

and dependence


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Keadaan putus alkoholOnset 12 jam sesudah minum terakhirPuncak 48-72 jam

Gejala: -halusinasi, ilusi- mual-muntah- flushed face-craving for alcohol

- imbalance electrolit


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Amphetamines and amphetamine-like drugs are themost widely used illicit(gelap) substances in the UnitedStates, Asia, Great Britain, Australia, and several otherwestern European countries

As a general class, the amphetamines are referred to asanaleptics, sympathomimetics, stimulants, andpsychostimulants

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

AMPHETAMINE (or AMPHETAMINE-LIKE)- RELATED DISORDER


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The classic amphetamines causing the release ofcatecholamines, particularly dopamine, frompresynaptic terminals

The effects are particularly potent for thedopaminergic neurons projecting from the ventraltegmental area to the cerebral cortex and the limbic

areas This pathway has been termed the reward circuit

pathway, and its activation is probably the majoraddicting mechanism for the amphetamines

The designer amphetamines cause the release of

catecholamines (dopamine and norepinephrine) andofserotonin, the neurotransmitter implicated as themajor neurochemical pathway for hallucinogens


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NARKOTIKA


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PENDAHULUAN

Narko t ika terdir i atas 3 go longan yai tu:

Opio id, Tanaman Ganja dan Kokain

Opioida adalah sejenis narkotika yang

mempunyai potensi ketergantungan yangpaling kuatbila dibandingkan dengan jenis

narkotika lainnya.


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OPIOID

Golongan opioid turunan opium dan zatsintetisnya: opium, morfin, diasetilmorfin ataudiamorfin dan lain-lain

Opioidefek menekan ("depresan") CNS, me

spontan aktivitas neuron, pusing, perubahanperasaan dan kesadaran berkabut.

Penggunaan opioida dengan cara: dragon, sniffing,puff, dan jarum suntik.

Intoksikasi opioidaoverdosiskematian. Intoksikasi Opioid


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OPIOID LANJUTAN

Terapi Detoksifikasi Opioida

terapi awal dari ketergantungan opioida mengeluarkanopioida dari dalam tubuh (3 hari sampai beberapa minggu).

Langkah dan beberapa alternatif pada terapi detoksifikasi adalah:

1. Tentukan diagnosis yang tepat dengan penemuan gejala-gejala objektif putus opioida

2.

Tujuan utama dari terapi detioksifikasi opioida adalahmengurangi penderitaan pasien, mencegah komplikasimedik dan menghindarkan pasien kembali menggunakanopioida

3. Metadon adalah opio ida sintet is yang bersifat agonis.Pemberian metadon merupakan standar terapi di banyak

negara

dianggap sebagaisubst i tus i op io ida dan do.

bertahap. Pada fase awal untuk menghilangkan gejala-gejala abstinensia, dosis metadon antara 20-40 mg per hari.


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NIKOTIN

Nikotin merupakan stimulansia yang

bekerja pada reseptor nikotin pada

susunan saraf pusat

Nikotin mempunyai efek pada sistem-

sistem kardiovaskuler,

gastrointestinalis, respiratorius dan

endokrin


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NIKOTIN

Nikotin merupakan stimulansia yang

bekerja pada reseptor nikotin pada

susunan saraf pusat

Nikotin mempunyai efek pada sistem-

sistem kardiovaskuler,

gastrointestinalis, respiratorius dan

endokrin


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Substance Related Disorder.ppt

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