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A1 A2 A3 A4
 Formula Diagnosis
Aksis I : dari anamnesis dan pemeriksaan fisik diketahui Tn. H memiliki
riwayat penggunaan rokok dan miras jenis figur sejak SMP serta shabu sejak
3 tahun yang lalu. Pasien terakhir menggunakan shabu 2 hari sebelum masuk
rumah sakit. Jumlah dan frekuensi penggunaan shabu 2 kali dalam satu
bulan. Terdapat beberapa gejala yang mengarah pada diagnostik sindrom
ketergantungan yaitu:

Adanya keinginan kuat untuk menggunakan zat, kesulitan mengendalikan

perilaku menggunakan zat sejak awal, keadaan putus zat secara fisiologis,
bukti toleransi yaitu peningkatan dosis psikoaktif untuk mendapatkan efek
yang sama, mengabaikan alternatif kesenangan lain karena zat psikoaktif dan
terus menggunakan zat meskipun sudah mengetahui akibatnya. Pasien juga
menandakan adanya gejala putus obat yaitu muncul gejala badan terasa
nyeri, gelisah, sulit konsentrasi dan mengalami gangguan tidur sehingga
pasien akan menggunakan shabu kembali.

Hal ini mengarahkan diagnosis menjadi F19.2 (Gangguan Mental dan

Perilaku Akibat Penggunaan Zat Multipel, Sindrom Ketergantungan) dan
F19.30 (Keadaan Putus Obat Tanpa Konvulsi)
 Formulasi Diagnosis

Aksis II Aksis IV
Berdasarkan anamnesis Terdapat masalah
tidak ditemukan gangguan berkaitan dengan
kepribadian Cluster A, Aksis II Aksis IV lingkungan sosial
Cluster B maupun C

Aksis III Aksis V

Aksis III Aksis V Pada skala penilaian
Tidak ditemukan
kelainan pada fungsi secara global,
pemeriksaan fisik dan ditemukan hendaya
hasil pemeriksaan sementara pada fungsi
laboratorium darah sosial dan pekerjaan. GAF
80-71
 Diagnosis Multiaksial

Aksis III
Tidak ada gangguan kepribadian

Aksis IV
Aksis II
Tidak ada gangguan kepribadian
Tidak ada gangguan kepribadian

Aksis I Aksis V
Gangguan Mental dan GAF 80-71
Perilaku Akibat Penggunaan
Zat Multipel, Sindrom
Ketergantungan (F 19.2) dan
Keadaan Putus Zat ( F19.3)
 Daftar Masalah

Psikologik
Tn. H mengeluhkan dirinya
merasa gelisah dan mudah
marah akhir-akhir ini setelah
menggunakan shabu.

Organobiologik
Tidak ditemukan adanya
kelainan fisik yang bermakna
berupa jantung berdebar-debar, Sosial/Keluarga
gemetar, mual dan sakit kepala. Tn. H merasa menjadi
beban bagi keluarga
terutama istrinya.
 Prognosis

Quo ad vitam : dubia ad bonam

Contents

Quo ad functionam: dubia ad bonam

Contents

Quo ad sanationam: dubia ad bonam

Contents
 Rencana Terapi
Medikamentosa

Chlorpromazine Trihexylphenidyl
1x12,5mg 2x2mg

Psikoterapi :
Support terhadap penderita dan keluarga, meminta pasien
berbicara pada orang terdekat apabila merasa gelisah.
Keluarga diminta mendampingi dan menjaga Tn. H agar
tidak mengonsumsi shabu dan miras kembali serta
mengurangi jumlah rokok. Tn.H diminta menjauhi
pergaulan dengan teman sekarang yang mengajak Tn.H
mengonsumsi zat-zat tersebut. Tn. H juga dibimbing sadar
akan kesehatannya karena kebiasaannya ini dapat
mengakibatkan dirinya sakit atau meninggal.
DISKUSI Apakah Diagnosis sudah tepat?

Menurut PPDGJ-III, Gangguan Penggunaan NAPZA terdiri atas

2 bentuk:

1. Penyalahgunaan, yaitu yang mempunyai harmful effects

terhadap kehidupan orang, menimbulkan problem kerja,
mengganggu hubungan dengan orang lain (relationship) serta
mempunyai aspek legal.

2. Adiksi atau ketergantungan, yaitu yang mengalami toleransi,

putus zat, tidak mampu menghentikan kebiasaan menggunakan,
menggunakan dosis NAPZA lebih dari yang diinginkan.
 Menurut PPDGJ-III: Diagnosis Ketergantungan Zat

ditegakkan jika ditemukan tiga atau lebih gejala di bawah ini dialami dalam masa setahun sebelumnya:
1. Adanya keinginan yang kuat atau dorongan yang memaksa (kompulsi) untuk menggunakan zat
2. Kesulitan dalam mengendalikan perilaku menggunakan zat sejak awal, usaha penghentian atau
tingkat penggunaannya
3. Keadaan putus zat secara fisiologis ketika penghentian penggunaan zat atau pengurangan, terbukti
orang tersebut menggunakan zat atau golongan yang sejenis dengan tujuan untuk menghilangkan
atau menghindari terjadinya gejala putus zat
4. Adanya bukti toleransi, berupa peningkatan dosis zat psikoaktif yang diperlukan guna memperoleh
efek yang sama yang biasanya diperoleh dengan dosis lebih rendah (contoh yang jelas dapat
ditemukan pada individu dengan ketergantungan alkohol dan opiat yang secara rutin setiap hari
menggunakan zat tersebutsecukupnya untuk mengendalikan keinginannya).
5. Secara progresif mengabaikan alternatif menikmati kesenangan karena penggunaan zat psikoaktif
yang lain, meningkatkan jumlah waktu yang diperlukan untuk mendapatkan atau menggunakan zat
atau pulih dari akibatnya
6. Terus menggunakan zat meskipun ia menyadari adanya akibat yang merugikan kesehatannya,
seperti gangguan fungsi hati kerana minum alkohol berlebihan,keadaan depresi sebagai akibat
penggunaan yang berat atau hendaya fungsi kognitif akibat menggunakan zat, upaya perlu
diadakan untuk memastikan bahwa pengguna zat bersungguh-sungguh atau diharapkan untuk
menyadari akan hakikat dan besarnya bahaya.
Keadaan Putus Zat

1. Keadaan putus zat merupakan salah satu indikator dari

sindrom ketergantungan dan diagnosisi sindrom
ketergantungan zat harus turut dipertimbangkan

2. Keadaan putus zat hendaknya dicatat sebagai diagnosis

utama, bila hal ini merupakan alasan rujukan dan cukupparah
smapi memerlukan perhatian medis secara khusus

3. Gejala fisik bervariasi sesuai zat yang digunakan. Gangguan

psikologis misalnya (ansietas, depresi dan gangguan tidur)
merupakn gambaran umum dari keadaan putus zat ini. Yang
khas ialah pasien akan melaporkan bahawa gejala putus zat
akan mereda degan meneruskan penggunaaan zat.
 Shabu dan
Rokok

Gangguan mental dan perilaku akibat

F 19.2 + penggunaan zat dengan sindrom
ketergantungan + keadaan putus zat tanpa
F 19.3 konvulsi

Memenuhi
kriteria sindrom
ketergantungan
dan keadaan
putus zat
Apakah Rencana Terapi sudah Tepat?

Berdasarkan Kepmenkes RI No 420 tentang Pedoman

Layanan Terapi dan Rehabilitasi Komprehensif pada
Gangguan Penggunaan NAPZA Berbasis Rumah Sakit,
tindakan penanganan pada pasien dengan penyalahgunaan
zat meliputi:

1.Gawat darurat NAPZA

2.Detoksifikasi
3.Rehabilitasi
4.Rawat jalan/Rumatan.
 Thank You
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