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Schizophrenia

Kristian Liaury MD, Ph.D, Psych.

Department of Psychiatry, Faculty of Medicine,


Hasanuddin University, Makassar
Schizophrenia / psychotic??
Schizophrenia / psychotic??
What is Psychosis?
• Tanda gejala, bukan gangguan
• Hendaya berat dalam menilai realita
• Tanda utama: halusinasi dan atau waham
• Gejala hendaya berat lainnya juga termasuk
Scope of psychosis

P
Mood disorders S
Y Substance
C induced
“organic”
H mental
“Functional” O disorders
disorders S Delirium
Schizophrenia
“spectrum” I Dementia
disorders S Amnestic d/o
SKIZOFRENIA
SKIZOFRENIA
GGN BERAT DLM BIDANG : PIKIRAN, PERASAAN, PERBUATAN,
PERSEPSI, KEINGINAN, DORONGAN KEHENDAK &
PENGENDALIAN

ONSET SULIT DITENTUKAN,BIASANYA DI DAHULUI FASE


PRODROMAL (GEJALA RINGAN & TDK KONSISTEN)

GEJALA PSIKOLOGIK MAJEMUK : DISTORSI PIKIRAN & PERSEPSI


→ WAHAM & HALUSINASI YG KHAS, AFEK TDK WAJAR /
TUMPUL, SIKAP/PERILAKU ANEH, PERASAAN & PIKIRAN
DIKETAHUI ORANG ATAU DIKENDALIKAN KEKUATAN GAIB DARI
LUAR

PERJALANAN PENY SULIT DITENTUKAN, KRONIS, DETERIORASI


TERGANTUNG : GENETIK, FISIK & SOSIAL BUDAYA.
Schizophrenia

• Schizophrenia occurs with regular frequency nearly


everywhere in the world in 1 % of population and
begins mainly in young age (mostly around 16 to 25
years).

• Schizophrenia is defined by
– a group of characteristic positive and negative symptoms
– deterioration in social, occupational, or interpersonal
relationships
– continuous signs of the disturbance for at least 1 months
History
• Emil Kraepelin: This illness develops relatively early in life, and
its course is likely deteriorating and chronic; deterioration
reminded dementia („Dementia praecox“), but was not
followed by any organic changes of the brain, detectable at that
time.
• Eugen Bleuler: He renamed Kraepelin’s dementia praecox as
schizophrenia (1911); he recognized the cognitive impairment
in this illness, which he named as a „splitting“ of mind.
• Kurt Schneider: He emphasized the role of psychotic symptoms,
as hallucinations, delusions and gave them the privilege of „the
first rank symptoms” even in the concept of the diagnosis of
schizophrenia.
4 A (Bleuler)
• Bleuler maintained, that for the diagnosis of schizophrenia are
most important the following four fundamental symptoms:
– affective blunting
– disturbance of association (fragmented thinking)
– autism
– ambivalence (fragmented emotional response)
• These groups of symptoms, are called „four A’ s” and Bleuler
thought, that they are „primary” for this diagnosis.
• The other known symptoms, hallucinations, delusions, which are
appearing in schizophrenia very often also, he used to call as a
“secondary symptoms”, because they could be seen in any other
psychotic disease, which are caused by quite different factors —
from intoxication to infection or other disease entities.
Course of Illness

Typical stages of schizophrenia:


– prodromal phase
– active phase
– residual phase
Dimensi Disabilitas Skizofrenia

Gejala Gejala
Positif Negatif
Interpersonal
Waham Perawatan diri
Ekspresi datar
Halusinasi
Kekacauan Kehilangan minat
pembicaraan ide
Kontak Katatonia motivasi

Sosial Pekerjaan
Gejala
Kognitif Gejala
Gangguan Perasaan
Pemanfaatan
Konsentrasi
Ketidaknyamanan
Kesejahteraan
Putus Asa
akses
Memori psikologis
Pikiran Bunuh Diri
Kemampuan
Perencanaan

Hervita Diatri, 2013


PEDOMAN DIAGNOSTIK UMUM

I. PALING KURANG 1 GEJALA


1. a. THOUGHT ECHO
b. THOUGHT INSERTION OR WITHDRAWAL
c. THOUGHT BROADCASTING

2. a. DELUSION OF CONTROL (WAHAM DIKENDALIKAN)


b. DELUSION OF INFLUENCE (WAHAM PENGARUH)
c. DELUSION OF PASSIVITY
d. DELUSION OF PERCEPTION
3. HALUSINASI PENDENGARAN
a. SUARA BERKOMENTAR TENTANG PERILAKUNYA
b. SUARA-SUARA SALING BERBICARA /
BERDISKUSI TENTANG HAL IHWALNYA
c. SUARA LAIN DARI SALAH SATU BAGIAN
TUBUHNYA

4. WAHAM MENETAP LAIN YG MENURUT


BUDAYA SETEMPAT DIANGGAP TDK WAJAR /
MUSTAHIL
II. PALING KURANG 2 GEJALA
5. HALUSINASI MENETAP DARI PANCA INDERA APA SAJA,
BISA DISERTAI WAHAM TANPA KANDUNGAN AFEKTIF YG
JELAS, ATAU IDE BERLEBIHAN YG MENETAP ATAU BILA
TERJADI SETIAP HARI SELAMA BERMINGGU2 / BERBLN
TERUS-MENERUS.

6. ARUS PIKIRAN TERPUTUS ATAU MENGALAMI SISIPAN →


INKOHERENSI, IRRELEVANSI ATAU NEOLOGISME.

7. PERILAKU KATATONIK : GADUH GELISAH, POSTURING,


FLEKSIBILITAS CEREA, NEGATIVISME, MUTISME, STUPOR.
8. GEJALA NEGATIF : APATIS, BICARA JARANG, RESPONS
EMOSIONAL YG TUMPUL / TDK WAJAR, PENARIKAN
DIRI DARI PERGAULAN SOSIAL, MENURUNNYA
KINERJA SOSIAL (BUKAN OLEH DEPRESI ATAU REAKSI
NEUROLEPTIKA)

9. SUDAH BERLANGSUNG 1 BULAN (DI LUAR FASE


PRODROMAL)

10. PERUBAHAN KONSISTEN BERMAKNA ASPEK PERILAKU


→ HILANGNYA MINAT, HIDUP TAK BERTUJUAN, TDK
BERBUAT SESUATU, LARUT DLM DIRI SENDIRI &
PENARIKAN DIRI SECARA SOSIAL.
Positive and Negative Symptoms

Negative Positive
Alogia Hallucinations
Affective flattening Delusions
Avolition-apathy Bizarre behaviour
Anhedonia-asociality Positive formal thought
disorder
Attentional impairment

Andreasen N.C., Roy M.-A., Flaum M.: Positive and negative symptoms. In: Schizophrenia,
Hirsch S.R. and Weinberger D.R., eds., Blackwell Science, pp. 28-45, 1995
I. SKIZOFRENIA PARANOID
• PALING SERING DITEMUKAN
• PEDOMAN DIAGNOSTIK
1. PED DIAGNOSTIK UMUM
2. HALUSINASI DAN / ATAU WAHAM HARUS MENONJOL :
a. SUARA MENGANCAM / MEMERINTAH, BUNYI
PLUIT, MENDENGUNG ATAU TAWA
b. PEMBAUAN / PENGECAP RASA. PERABAAN YG
BERSIFAT SEKSUAL, JARANG VISUAL
c. WAHAM HAMPIR SETIAP JENIS, TETAPI PALING
KHAS ADALAH DIKENDALIKAN, DIPENGARUHI,
PASSIVITY DAN DIKEJAR-KEJAR
II. SKIZOFRENIA HEBEFRENIK
• ONSET BIASA PD UMUR < MUDA
• PEDOMAN DIAGNOSTIK
1. PED DIAGNOSTIK UMUM
2. DIAGNOSTIK PERTAMA KALI PD USIA REMAJA ATAU DEWASA
MUDA (15-25 THN)
3. KEPRIBADIAN PREMORBID CIRI KHAS : PEMALU, SENANG
MENYENDIRI
4. UTK DIAGNOSIS DIPERLUKAN PENGAMATAN KONTINU 2-3 BLN
a. MANNERISME, CENDERUNG MENYENDIRI, HAMPA
TUJUAN / PERASAAN
b. AFEK DANGKAL & TDK WAJAR, CEKIKIKAN, RASA
PUAS DIRI, SENYUM SENDIRI, TAWA
MENYERINGAI, UNGKAPAN KATA DI ULANG-ULANG
c. PROSE PIKIR DISORGANISASI, PEMBICARAAN TDK
MENENTU, INKOHERENSI
5. DORONGAN KEHENDAK HILANG, TDK ADA MINAT, KADANG
INGIN BERBUAT SESUATU TAPI SEGERA DITINGGALKAN,
PREOKUPASI YG DANGKAL DGN TEMA ANEH → SULIT
MEMAHAMI JALAN PIKIRAN
III. SKIZOFRENIA KATATONIK
• YG MENONJOL GAMBARAN PSIKOMOTOR : HIPEKINESIS,
STUPOR, OTOMATISME & NEGATIVISME

• PEDOMAN DIAGNOSTIK
1. PED DIAGNOSTIK UMUM
2. > 1 PERILAKU MENDOMINASI GAMBARAN KLINISNYA
a. STUPOR ATAU MUTISME
b. GADUH GELISAH
c. POSTURING (TDK WAJAR & ANEH)
d. NEGATIVISME
e. RIGIDITAS
f. FLEKSIBILITAS CEREA
g. GEJALA LAIN : COMMAND AUTOMATISM,
VERBIGERASI, EKOLALI & EKOPRAKSI
IV. SKIZOFRENIA SIMPLEKS
• SULIT DIBUAT
• PEDOMAN DIAGNOSTIK
GEJALA KRONIK PROGRESIF DARI :
a. GEJALA NEGATIF SKIZOFRENIA
RESIDUAL TANPA DIDAHULUI GEJALA
POSITIF
b. PERUBAHAN PERILAKU PRIBADI,
HILANG MINAT, TDK BERBUAT
SESUATU, TANPA TUJUAN HIDUP &
PENARIKAN DIRI SECARA SOSIAL
Etiology of Schizophrenia

• The etiology and pathogenesis of


schizophrenia is not known

• It is accepted, that schizophrenia is „the group


of schizophrenias“ which origin is
multifactorial:
– internal factors – genetic, inborn, biochemical
– external factors – trauma, infection of CNS, stress
Genetics of Schizophrenia

• Many psychiatric disorders are multifactorial (caused


by the interaction of external and genetic factors)
and from the genetic point of view very often
polygenically determined.

• Relative risk for schizophrenia is around:


– 1% for normal population
– 5.6% for parents
– 10.1% for siblings
– 12.8% for children
Etiology of Schizophrenia - Dopamine
Hypothesis
• The most influential and plausible are the hypotheses, based on
the supposed disorder of neurotransmission in the brain, derived
mainly from
1. the effects of antipsychotic drugs that have in common the ability to
inhibit the dopaminergic system by blocking action of dopamine in the
brain
2. dopamine-releasing drugs (amphetamine, mescaline, diethyl amide of
lysergic acid - LSD) that can induce state closely resembling paranoid
schizophrenia

• Classical dopamine hypothesis of schizophrenia: Psychotic


symptoms are related to dopaminergic hyperactivity in the brain.
Hyperactivity of dopaminergic systems during schizophrenia is
result of increased sensitivity and density of dopamine D2
receptors in the different parts of the brain.
Etiology of Schizophrenia -
Contemporary Models
• Dopamine hypothesis revisited: various neurotransmitter
systems probably takes place in the etiology of schizophrenia
(norepinephric, serotonergic, glutamatergic, some peptidergic
systems); based on effects of atypical antipsychotics
especially.

• Contemporary models of schizophrenia conceptualize it as a


neurocognitive disorder, with the various signs and symptoms
reflecting the downstream effects of a more fundamental
cognitive deficit:
– the symptoms of schizophrenia arise from “cognitive dysmetria”
(Nancy C. Andreasen)
– concept of schizophrenia as a neurodevelopmental disorder (Daniel R.
Weinberger)
Etiology of Schizophrenia -
Neurodevelopmental Model
• Neurodevelopmental model supposes in schizophrenia the
presence of “silent lesion” in the brain, mostly in the parts,
important for the development of integration (frontal, parietal
and temporal), which is caused by different factors (genetic,
inborn, infection, trauma...) during very early development of
the brain in prenatal or early postnatal period of life.
• It does not interfere too much with the basic brain functioning
in early years, but expresses itself in the time, when the
subject is stressed by demands of growing needs for
integration, during formative years in adolescence and young
adulthood.
More modern approaches emphasize other transmitter systems, too

“1-Dopamine adjusts
the volume—Blocked
by antipsychotics

2-Acetycholine and
GABA filter signal
from noise

3-Glutamate imprints
new memories”

30
Robert Freedman
Psychosocial Factors
• Expressed emotion
• Stressful life events
• Low socioeconomic class
• Limited social network
Treatment Goal of Schizophrenia

Productivity
Subjective (school, earning
money or being a
Quality of
volunterary
Life Recovery worker) GAF  65
Harding, dkk 1987

Symtoms
(Free of
symtoms &
without
medicine,2
yrs)
Lieberman, et
all, 2002
Goals of Pharmacotherapy for Schizophrenia

Recovery

Remission
Symtoms & function
Cognitive & Insight Functionality
Remisssion
(symtoms mild or less for
6 months)

Resolusion
(symtoms   no time limit)

Response

Acute Episode
The Continuum of Care

Efficacy
Positive symptom relief Negative symptom relief
Hostility, aggression Improve mood and
Smooth IM to PO transition depressive symptoms R
Cognitive improvement e
Control
Behavior
Relapse Prevention
c
(agitation)
1-3 days 7-14 days 6+ months
o
Acute dystonia EPS TD
v
Sedation
Orthostasis
Drug-drug interactions Hyperprolactinemia e
QTc prolongation Weight gain
QTc prolongation Hyperglycemia r
QTc prolongation
y
Safety
Treatment of Schizophrenia
• The acute psychotic schizophrenic patients will respond usually
to antipsychotic medication.
• According to current consensus we use in the first line therapy
the newer atypical antipsychotics, because their use is not
complicated by appearance of extrapyramidal side-effects, or
these are much lower than with classical antipsychotics.

chlorpromazine, chlorprotixene, clopenthixole,


conventional levopromazine, periciazine, thioridazine
antipsychotics droperidole, flupentixol, fluphenazine, fluspirilene,
(classical haloperidol, melperone, oxyprothepine, penfluridol,
neuroleptics) perphenazine, pimozide, prochlorperazine,
trifluoperazine
atypical amisulpiride, clozapine, olanzapine, quetiapine,
antipsychotics risperidone, sertindole, sulpiride
Typical Neuroleptics
• Low potency: • High potency:
– Chlorpromazine – Haloperidol
– Thioridazine – Fluphenazine
– Mesoridazine – Thiothixene
– Loxapine (mid)
Neuroleptic (typicals):
side effects
• Acute dystonia
• Parkinsonian side effects (EPS)
• Akathisia
• Tardive dyskinesia
• Sedation, orthostasis, QTC prolongation,
anticholinergic, lower seizure threshold,
increased prolactin
Atypical Antipsychotics:
• Risperidone
• Olanzapine
• Quetiapine
• Clozapine
• Ziprasidone
• Aripiprazole (new-partial DA agonist)
Atypical Antipsychotics: Side Effects
• Sedation
• Hyperglycemia, new-onset diabetes
• Anticholinergic effects
• Less prolactin elevation
• QTC prolongation
• Some EPS
• Increased lipids
Pedoman Penatalaksanaan Gangguan Skizofrenia
Prognosis
• 22% have one episode and no residual
impairment
• 35% have recurrent episodes and no residual
impairment
• 8% have recurrent epsiodes and develop
significant non-progressive impairment
• 35% have recurrent episodes and develop
significant progressive impairment
Predictors of treatment outcome

Poor Male
premorbid sex
Early age of
adjustment onset

Longer Poor medication


duration of POOR adherence
untreated OUTCOME
psychosis

Inherent Reduced brain


refractoriness volume
Cognitive
impairment

Modifiable factors
44 Robinson et al. Am J Psychiatry 2004;161:473–479; Emsley et al. J Clin Psychiatry 2006;67:1707–1712
Prognosis contd.
• Good outcome is associated with:
– Female
– Older age of onset
– Married
– Higher SEG
– Living in a developing (as opposed to developed) country
– Good premorbid personality
– No previous psych history
– Good education and employment record
– Acute onset, affective symptoms, good compliance with meds
Prognosis contd.
• Some of the predictors of outcome are the
consequence of a less severe illness

• Predicting risk of suicide


» Acute exacerbation of psychosis
» Depressive symptoms
» History of attempted suicide
“He saw the world in a way no one could have imagined.”

47
48
GANGGUAN SKIZO AFEKTIF
• TERDPT GGN AFEKTIF & GEJALA SKIZOFRENIA PD SAAT
BERSAMAAN
• PEDOMAN DIAGNOSTIK UMUM :
1. TERDPT GEJALA2 SKIZOFRENIA & GGN
AFEKTIF SAMA MENONJOL PD SAAT
BERSAMAAN
2. TDK BOLEH ADA GEJALA SKIZOFRENIA &
GGN AFEKTIF DLM EPISODE PENYAKIT YG
TERPISAH
3. BILA SEORANG SKIZOFRENIA MENUNJUKKAN
GEJALA2 DEPRESIF SETELAH MENGALAMI
SUATU EPISODE PSIKOTIK DIBERI
DIAGNOSIS DEPRESI PASCA SKIZOFRENIA
I. GGN SKIZO AFEKTIF TIPE MANIK
PEDOMAN DIAGNOSTIK :

1. PED DIAGNOSTIK UMUM


2. ADA EPISODE SKIZOAFEKTIF MANIK YG TUNGGAL
MAUPUN BERULANG DGN SEBAGIAN BESAR TIPE
MANIK.
3. AFEK HRS MENINGKAT SECARA MENONJOL ATAU TAK
BEGITU MENONJOL TETAPI DISERTAI IRITABILITAS
ATAU KEGELISAHAN YG MEMUNCAK.
4. DLM EPISODE YG SAMA HRS JELAS ADA SATU ATAU
LEBIH BAIK LAGI KALAU DUA GEJALA SKIZOFRENIA YG
KHAS.
II. GGN SKIZOAFEKTIF TIPE DEPRESIF
PEDOMAN DIAGNOSTIK
1. PED DIAGNOSTIK UMUM
2. ADA EPISODE SKIZOAFEKTIF TIPE DEPRESIF YG
TUNGGAL MAUPUN BERULANG DGN SEBAGIAN BESAR
TIPE DEPRESIF
3. AFEK DEPRESIF HRS MENONJOL DISERTAI OLEH
SEDIKITNYA DUA GEJALA KHAS, BAIK DEPRESIF
MAUPUN KELAINAN PERILAKU TERKAIT SEPERTI
TERCANTUM DLM URAIAN UTK KRITERIA EPISODE
DEPRESIF
4. DLM EPISODE YG SAMA HRS JELAS ADA SEDIKITNYA
SATU ATAU LEBIH LAGI KALAU DUA GEJALA KHAS
SKIZOFRENIA
III. GGN SKIZOAFEKTIF TIPE CAMPURAN

• GGN DGN GEJALA2 SKIZOFRENIA BERADA


SECARA BERSAMA-SAMA DGN GEJALA-GEJALA
AFEKTIF BIPOLAR CAMPURAN
GGN PSIKOTIK AKUT & SEMENTARA
• ONSET AKUT ; YAITU PERUBAHAN DARI KEADAAN TANPA
GEJALA PSIKOTIK KE KEADAAN PSIKOSIK YG TERJADI DLM
WAKTU 2 MINGGU ATAU KURANG SEBAGAI CIRI KHAS YG
MENENTUKAN SELURUH KLP
• ADANYA SINDROM YG KHAS ; YG DIPILIH PERTAMA IALAH
KEADAAN YG BERANEKA RAGAM SERTA BERUBAH CEPAT YG
DINAMAKAN POLIMORFIK, SEDANG YG KEDUA IALAH ADANYA
GEJALA2 SKIZOFRENIA YG KHAS
• TERDPTNYA STRES AKUT TERKAIT, YG DIANGGAP SECARA LAZIM
BERHUBUNGAN DGN TIMBULNYA PSIKOSIS AKUT.
• LAMANYA BERLANGSUNG SULIT DIPASTIKAN, SERINGKALI DLM
BEBERAPA MINGGU ATAU BAHKAN DLM BEBERAPA HARI TETAPI
KADANGKALA DLM 2-3.
• DAHULU DISEBUT : PSIKOSIS REAKTIF SINGKAT
• PEDOMAN DIAGNOSTIK :
 ADANYA CIRI2 UTAMA TERPILIH DARI GGN INI DLM
URUTAN PRIORITAS SBB :
1. ONSET AKUT ; DLM JANGKA WAKTU 2 MGG ATAU
KURANG, GEJALA2 PSIKOTIK SDH NYATA &
MENGGANGGU SEDIKITNYA BBRP ASPEK
KEHIDUPAN & PEKERJAAN SEHARI2.
2. ADA SINDROM KHAS BERUPA “POLIMORFIK”
ARTINYA ADA ANEKA RAGAM GEJALA & BERUBAH
CEPAT ATAU GEJALA SKIZOFRENIA YG KHAS.
3. ADA STRES AKUT TERKAIT, NAMUN TAK PERLU
SELALU ADA
 TDK MEMENUHI KRITERIA EPISODE MANIK ATAU
DEPRESIF, WALAUPUN PERUBAHAN EMOSIONAL &
GEJALA2 AFEKTIF DPT MENONJOL DARI WAKTU KE
WAKTU.
 TDK ADA PENYEBAB ORGANIK ATAU INTOKSIKASI AKIBAT
PENGGUNAAN ZAT.
I. GGN PSIKOTIK POLIMARFIK AKUT TANPA
GEJALA SKIZOFRENIA

• PEDOMAN DIAGNOSTIK
1. PEDOMAN DIAGNOSTIK UMUM
2. HALUSINASI ATAU WAHAM YG BERUBAH DLM JENIS
& INTENSITASNYA
3. KEKALUTAN EMOSIONAL YG ANEKA RAGAM & LEBIH
SERING SENANG, SEDIH, CEMAS ATAU MARAH
4. GEJALA YG ANEKA RAGAM ITU TAK SATUPUN
SECARA CUKUP KONSISTEN DPT MEMENUHI KRITERIA
SKIZOFRENIA, EPISODE MANIK ATAU DEPRESIF

• DISEBUT JUGA BOUFFEE DELIRANTE, PSIKOSIS SIKLOID TANPA


GEJALA SKIZOFRENIA
II. GGN PSIKOTIK POLIMARFIK AKUT DGN GEJALA
SKIZOFRENIA

• PEDOMAN DIAGNOSTIK
1. MEMENUHI KRITERIA 1, 2, & 3 GGN
PSIKOTIK POLIMORFIK AKUT TANPA
GEJALA SKIZOFRENIA
2. DISERTAI GEJALA2 YG MEMENUHI
KRITERIA D/ SKIZOFRENIA YG SUDAH
HRS ADA UTK SEBAGIAN BESAR WAKTU
SEJAK MUNCULNYA GAMBARAN KLINIS
PSIKOSIS ITU SECARA JELAS.
3. JIKA GEJALA SKIZOFRENIA MENETAP
LEBIH DARI 1 BLN MAKA DIAGNOSIS HRS
DIRUBAH → SKIZOFRENIA
III. GGN PSIKOTIK LIR-SKIZOFRENIA AKUT
• PEDOMAN DIAGNOSTIK
1. PEDOMAN DIAGNOSTIK UMUM
2. GEJALA2 YG MEMENUHI KRITERIA UTK SKIZOFRENIA
YG HRS SDH ADA UTK SEBAGIAN BESAR WAKTU SEJAK
MUNCULNYA GAMBARAN PSIKOTIK YG JELAS
3. TAK ADA ATAU KALAU ADA GEJALA LAIN SANGAT
MINIM RAGAMNYA, SANGAT SEMENTARA &
INTENSITASNYA RINGAN
4. JIKA GEJALA SKIZOFRENIA MENETAP LEBIH DARI 1
BLN MAKA DIAGNOSIS HRS DIRUBAH → SKIZOFRENIA

• DAHULU JENIS INI DISEBUT :


1. SKIZOFRENIA AKUT ATAU REAKSI SKIZOFRENIA
2. GGN ATAU PSIKOSIS SKIZOFRENIFORM SINGKAT
3. ONEIROFRENIA
IV. GGN PSIKOTIK AKUT PREDOMINAN
WAHAM

• UNTUK D/ PASTI:
– ONSET GEJALA PSIKOTIK HRS AKUT
– WAHAM & HALUSINASI HRS SUDAH ADA DLM SEBAGIAN
BESAR WKT SEJAK BERKEMBANGNYA KEADAAN PSIKOTIK
YG JELAS
– TDK MEMENUHI KRITERIA SKIZOFRENIA MAUPUN
PSIKOTIK POLIMORFIK AKUT
• KALAU WAHAM MENETAP > 3 BLN  GGN WAHAM
MENETAP, KALAU HALUSINASI MENETAP > 3 BLN
GGN PSKOTIK NON-ORGANIK LAINNYA