PENATALAKSANAAN STRES AKIBAT TRAUMA FISIK

PENANGANAN EFEK PSIKIS AKIBAT TRAUMA FISIKRh Budhi MuljantoPENANGANAN EFEK PSIKIS AKIBAT TRAUMA FISIK

Definition of TraumaPsychological trauma is generally seen as the reaction following exposure to an over- whelming experience that is out of control and to which earlier coping strategies are found to be insufficient. (Herman,Terr1992).

Jenis-jenis TraumaBencana alamPenculikanKekerasan di sekolahKekerasan kehidupanKekerasan di masyarakatTerorisme/perangKorban tindakan kriminalRudapaksa fisikRudapaksa SexualPercobaan PembunuhanTindakan medisKecelakaanPercobaan Bunuh diriPenelantaran yang sangat menyakitkan4TBI in the United States

50,000 Deaths235,000Hospitalizations1,111,000Emergency Department Visits??? Receiving Other Medical Care or No CareAt least 1.4 million TBIs occur in the United States each year.** Average annual numbers, 1995-2001CDC, 20064%17%57 million livingWith TBI WorldwideFrom 1995 to 2001, an average of 1.4 million TBIs occurred in the United States each year. Of them, most (79.6%) were ED visits, followed by hospitalizations (16.8%) and deaths (3.6%).Traumatic Brain Injury (TBI)Neurobiological Injury

Traumatic Event

Chronic Medical Illness

TBI as Neurobiological InjuryPrimary effects of TBIContusions, diffuse axonal injurySecondary effects of TBIHematomas, edema, hydrocephalus, increased intracranial pressure, infection, hypoxia, neurotoxicity, inflammatory response, protease activation, calcium influx, excitotoxin & free radical release, lipid peroxidation, phospholipase activationCan affect serotonin, norepinephrine, dopamine, acetylcholine, and GABA systemsTBI-associated DisabilityPostconcussive Symptoms

CognitivePhysical: sensory and motorEmotional

VocationalSocialFamilyNeuropsychiatric SequelaeDelirium Depression / ApathyManiaAnxietyPsychosisCognitive Impairment Aggression, Agitation, ImpulsivityPostconcussive SymptomsNeuropsychiatric Evaluation and Treatment: Etiologies PsychiatricNeurologic/MedicalSocial

PremorbidNeurologic illnessSocial, family, vocation Psych disorders & sxs. Lesion location, size,Rehabilitation situation Personality traits pathophysiology and stressors Coping stylesOther medical illnessFunctional impairmentSubstance AbuseOther indirect sequelaeMedicolegalMedication side effects (e.g., pain, sleep disturb) & interactionsMedication side effectsPsychodynamic sig. & interactions of neurologic illnessFamily psych. history

Roy-Byrne P, Fann JR. APA Textbook of Neuropsychiatry, 1997Neuropsychiatric Evaluation and Treatment: Workup PsychiatricNeurologic/MedicalSocial

Psychiatric history &Medical history and Interview family, friends, examination physical examination caregiversNeuropsychologicalAppropriate lab testsAssess level of care & testing e.g., CBC, med blood supervision availablePsychodynamic signif. of levels, CT/MRI, EEGAssess rehab needs neuropsychiatric sxs.,Medication allergies & progress disability and treatments

Neuropsychiatric Evaluation and Treatment: Follow-up PsychiatricNeurologic/MedicalSocial

Frequent pharmacologicPhysical signs & sxs.Rehabilitation monitoringPhysiologic responseMaximize supportPsychotherapy (e.g., vital signs) systemIntermittent cognitiveAppropriate lab tests assessments (e.g., CBC, medicationSupport Groups blood levels, EEG)

Neuropsychiatric HistoryPsychiatric symptoms may not fit DSM-IV criteriaFocus on functional impairment Document and rate symptomsExplore circumstances of traumaLOC, PTA, hospitalization, medical complicationsSubtle symptoms - may fail to associate with traumaHow has life changed since TBI?Thorough review of medical and psychiatric sxs.Talk with family, friends, caregiversAssess level of care and supervision availableAssess rehabilitation needs and progress

Traumatic eventcuesTERAPITerapi pilihan: Psikoterapi

Psikofarmaka bukan yang utama, bila perlu, diberikan hanya untuk target gejala yang muncul saja

Mengembalikan kemampuan pasien mengendalikan emosinya

Neuropsychiatric TreatmentUse Biopsychosocial ModelTreat maximum signs and symptoms with fewest possible medications TBI patients more sensitive to side effects START LOW, GO SLOWMay still need maximum dosesTherapeutic onset may be latentMedications may lower seizure thresholdMedications may slow cognitive recoveryMonitor and document outcomesFew randomized, controlled trialsKONSELING Merupakan suatu proses dimana seseorang membantu orang lain dlm menyelesaikan permasalahan atau membuat keputusan dengan memahami fakta-fakta dan emosi yang terlibat.

KONSELOR adalah seorang yang memberikan konseling.

KLIEN adalah seorang yang mendapat konseling. TUJUAN KONSELINGMerawat & menjaga keswa seseorangMengembalikan fungsi seseorangMenyelesaikan masalah seseorangMenemukan cara lain pemecahan masalahMempelajari teknik-teknik menghadapi dan menyelesaikan masalahMemberikan kemampuan pemahaman diriMembangun kemampuan mengambil keputusanMenyediakan informasiKONSELINGBerfokus/spesifik kebutuhan/masalahBerfokus pada tujuanProses timbal balikMemperhatikan situasi interpersonalMengajukan pertanya an, menyediakan informasi, mengembangkan rencana tindakanMengarahkan /menyarankanMenasehatiObrolanInterogasiWawancaraPengakuanCurhatDoaharapanSYARAT MENJADI KONSELOR/FASILITATORMenerima klien apa adanyaBersifat optimisMampu simpan rahasiaSansitif menilai Mampu beri informasiFleksibelDpt menghargai orang lainMampu jadi tem-pat bergantungTerbuka dan JujurBersikap tidak menilaiPercaya diriPunya rasa humorPendengar yg baikTerampil dlm membantuDapat berempati intonasi suara, cara bicara, jeda kata bibir, kerut dahi, alis, hidung, tatap mata dan kesesuaian antara pandangan matabibir- hidung Memahami perilaku /komunikasi non verbal klien

makro kinetik: gerakan tubuh-tangan-kaki-sikap tubuh pupil melebar, nafas tersengal, wajah merah pucat, berkeringat Cara berpakaian, sikap dalam duduk dan berdiri Ekspresi Wajah SuaraPenampilanPerilaku TubuhReaksi Fisiologis22 Yang boleh dilakukan (DOs)Dekati mereka secara aktifDengarkan merekaEmpati, hindari simpatiHargai martabat merekaTerima dan hargai pandangan mereka tentang masalahnyaKetahui kebutuhan mereka untuk privacy dan confidentialJamin perawatan yang berkelanjutan Yang tidak boleh dilakukan (DONTs)

Jangan paksakan dukungan dan bantuan pada merekaJangan interupsi mereka bila mereka sedang menyatakan emosinyaJangan mengasihati merekaJangan menghakimi merekaJangan sebarkan rumorJangan melabel mereka dengan gangguan psikiatri ( lebih baik rujuk ke dokter atau profesi keswa) EMPATI > < SIMPATISaya dapat memahami apa yang terjadi pada andaSaya dapat memahami bahwa anda merasa marah terhadap apa yang terjadi pada andaSaya dapat menerima bahwa anda sangat takut, hampir semua orang juga merasakan seperti yang anda rasakan Sungguh malang anda, ini benar-benar nasib buruk yg terjadi pd andaSaya juga marah dan kita akan mengatasinya bersama-samaJangan takut, Saya disini untuk membantu anda apapun yg anda butuhkanSaya mohon maaf sama anda, jangan khawatir semuanya akan menjadi lebih baikCARA MEMAHAMI PENGALAMAN KLIENMenerima klien apa adanyaMembina hubungan baik dan slg percayaDengarkan dg seksamaPerhatikan apa yg mereka katakan dan yg tidak dikatakan krn merupakan pengalaman pahit. Bila sudah terjalin slg percaya baru mereka akan menceritakan pengalaman pahit, kecemasan dan perasaan lain. Semakin mampu mereka menghadapi perasaan, semakin cepat baik5.Tanyakan lebih rinci sehingga anda memahaminya. Kadangkala perlu waktu untuk mengungkap perasaannya6.Bantu mereka untuk mengetahui perasaan yang timbul, bukan hanya bicara tentang fakta. Katakan bahwa hal itu merupakan reaksi alamiah. Bila anda ragu tanyakan lagi agar lebih jelas7.Bantu mereka agar berbicara tentang perasaannyaBersama-sama membicarakan jalan keluar yang dapat dilakukanJangan menghakimiJangan menjanjikan yang tak mungkin terjadi, misalnya bila anaknya cacat dikatakan nanti akan bisa berjalan kembali. Lebih baik bicarakan perasaannya tentang hal itu dan apa yang dapat dia lakukan untuk perbaikanJangan melanggar janji kerahasiaanBANTU PEMECAHAN MASALAH1. MEMAHAMI MASALAH:Dr informasi yg disampaikan cari akar masalah Cari jalan keluar satu persatu shg lebih mudah untuk dipecahkan

2. CARI LANGKAH YG BERBEDA UNTUK PEMECAHAN MASALAHDiskusikan tiap masalah dan bantu mencari jalan keluar yg berbedaBuat rencana dan jadwalkan waktu untuk melakukanGali kemampuannya untuk memecahkan masalahBl mereka tak ada ide anda ajukan usul3. MEMUTUSKAN JALAN KELUAR TERBAIK:Cari setiap kemungkinan, bantu mempertimbangkan segi baik buruk setiap pemecahan masalah Setelah ada pilihan jalan keluar buat kesimpulan dlm kalimat yg dpt dimengertiTanyakan apakah mereka setuju dg kesimpulan yg dibuatDiskusikan apa saja yg hrs dilakukan

4. LANGKAH YG HRS DILAKUKANBantu mencari cara yg dpt dilakukanDiskusikan perasaan mereka sp mereka dpt memutuskan cara yg dianggap cocokBERI KEPASTIAN BHW MEREKA MAMPU MELAKUKAN

Bicarakan ttg pilihanBerikan bbrp pilihan lain yg mungkin blm diketahuinya Ajak melihat ke masa depan: hal yg dpt menghambat dan cara mengatasiDukung rasa percaya diri bhw dia telah berani mengambil keputusan

TERIMA KASIHTable 16.5-5 DSM-IV-TR Diagnostic Criteria for Acute Stress DisorderThe person has been exposed to a traumatic event in which both of the following were present: the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others the person's response involved intense fear, helplessness, or horrorEither while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms: a subjective sense of numbing, detachment, or absence of emotional responsiveness a reduction in awareness of his or her surroundings (e.g., being in a daze) derealization depersonalization dissociative amnesia (i.e., inability to recall an important aspect of the trauma)The traumatic event is persistently reexperienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience; or distress on exposure to reminders of the traumatic event. Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, people). Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness). The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or impairs the individual's ability to pursue some necessary task, such as obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience. The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition, is not better accounted for by brief psychotic disorder, and is not merely an exacerbation of a preexisting Axis I or Axis II disorder.

(From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington, DC: American Psychiatric Association; copyright 2000, with permission.)Table 16.5-4 DSM-IV-TR Diagnostic Criteria for Posttraumatic Stress DisorderThe person has been exposed to a traumatic event in which both of the following were present: the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others the person's response involved intense fear, helplessness, or horror.Note: In children, this may be expressed instead by disorganized or agitated behavior. The traumatic event is persistently reexperienced in one (or more) of the following ways: recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed. recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content. acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur. intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: efforts to avoid thoughts, feelings, or conversations associated with the trauma efforts to avoid activities, places, or people that arouse recollections of the trauma inability to recall an important aspect of the trauma markedly diminished interest or participation in significant activities feeling of detachment or estrangement from others restricted range of affect (e.g., unable to have loving feelings) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span) Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following: difficulty falling or staying asleep irritability or outbursts of anger difficulty concentrating hypervigilance exaggerated startle response Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.Specify if:Acute: if duration of symptoms is less than 3 monthsChronic: if duration of symptoms is 3 months or moreSpecify if:With delayed onset: if onset of symptoms is at least 6 months after the stressor

Threat/Stress
Hypothalamus(CRH, AVP)

Modulates, inhibitsHPA Axis
Adrenal Cortex(Cortisol)

Cardiovascular adaptationVigilanceCatabolismImmune suppressionGrowth suppression

Mediates
Anterior Pituitary(ACTH)
THE HYPOTHALAMIC/PITUITARY/ADRENAL AXIS