Curriculum Vitae dr.Andri,SpKJ,FAPM Lahir : Tangerang , 19 Desember 1978 Pendidikan formal :

1. Curriculum Vitae dr.Andri,SpKJ,FAPM Lahir : Tangerang, 19 Desember1978 • Pendidikan formal : • Dokter : FKUI Lulus 2003 • Psikiater : FKUI lulus 2008 • Pendidikantambahan: • Psychosomatic Medicine Course dari American Psychosomatic Society tahun 2010 dan Continuing and Update Course in Psychosomatic Medicine dari Academy of Psychosomatic Medicine 2012 dan 2013 • Pengakuansebagai Fellow Academy of Psychosomatic Medicine (FAPM) : 18 September 2013 • Keanggotaanorganisasi • IDI, PDSKJI, American Psychosomatic Society, Academy of Psychosomatic Medicine • Jabatansaatini • Dosen Psikiatri di FK UKRIDA, Jakarta • KepalaKlinikPsikosomatik Omni Hospital, AlamSutera • Ketua Sub KredensialKomiteMedik RS OMNI AlamSutera • Kepala Unit Riset FK UKRIDA

2. Psychosis in Medically Ill Patient ANDRI mbahndi@yahoo.com Division of Psychiatry Universitas Kristen Krida Wacana (UKRIDA) Arjuna Utara no.6 Jakarta Barat 11510 www.ukrida.ac.id

3. Introduction • Are psychiatric symptoms attributable to a primary psychiatric syndrome? Or are they secondary to medical disease, substance use or medication intoxication?

4. Diagnosis and Assessment Psychotic symptoms in a medically hospitalized patient fall into one of three possibilities : • Primary psychiatric illness • New-onset or an acute exacerbation of psychiatric illness associated with psychosis • Secondary psychosis • Psychosis due to a general medical condition (systemic or brain-based) • Substance induced psychosis • Medication-induced psychosis • Secondary on Primary • A patient with a primary psychotic disorder has psychosis unrelated to his or her primary psychotic disorder

5. Clinical Case (1) • A 52-years old male patient with diagnosis subarachnoid and subdural hemorrhage after motorcycle traffic accident. • The attending neurosurgeon planned a craniotomy operation to the patient. • Thirteen days after the operation a psychiatrist was consulted because patient was agitated, performed aggressive behavior, irritable and more silent than he used to be • A psychiatric consultation was performed and major depression disorder with aggressive behavior was the diagnosis at that time. • Haloperidol 2.5mg bid and Sertraline 25mg on the morning was given to patient. • Patient was discharged two days after the consultation.

6. Clinical Case (2) • Three weeks after the last consultation, patient started to experience auditory and visual hallucination. • The treatment program was modified based on the patient condition at that time. • I used Risperidone 2x1mg, Sertraline 1x50mg • A month after the last consultation, psychotic symptoms were improved • Mood was improved but patient remained irritable, became more stubborn, acting out, dis-inhibition and frequently forgot the order of task. • I stopped Risperidone, but still used Sertraline

7. Diagnosis Diagnostic criteria for 293.xx Psychotic Disorder Due to . . . [Indicate the General Medical Condition] A. Prominent hallucinations or delusions. B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition. C. The disturbance is not better accounted for by another mental disorder. D. The disturbance does not occur exclusively during the course of a delirium. Code based on predominant symptom: .81 With Delusions: if delusions are the predominant symptom .82 With Hallucinations: if hallucinations are the predominant symptom Coding note: Include the name of the general medical condition on Axis I, e.g., 293.81 Psychotic Disorder Due to Malignant Lung Neoplasm, With Delusions; also code the general medical condition on Axis III. Coding note: If delusions are part of Vascular Dementia, indicate the delusions by coding the appropriate subtype, e.g., 290.42 Vascular Dementia, With Delusions.

8. Clinical features Primary Psychosis Secondary psychosis Psychotic symptoms first appear at an older age and if there is no personal or family history of primary psychotic disorders. If the course of the psychotic symptoms parallels the course of the medical disorder suspected as cause, a diagnosis of secondary psychosis is more likely • Cognitive function and level of consciousness are relatively normal • Focal neurological signs are absent • Hallucinations are most often auditory, delusions tend to be complex • Thought disorder may be prominent, • Incontinence is usually absent, • Vital signs are usually normal

9. Medical Evaluation • Laboratory Evaluation • Complete blood count • Electrolytes including calcium and phosphate • Serum urea nitrogen/creatinine • Glucose • Liver function tests • HIV Test • Vitamin B12 and folate • Serum Cortisol level • Urynalisis • Urine cultures • Blood cultures • Brain Imaging • MRI • EEG

10. Medical Disorders Causing Secondary Psychosis Metabolic Disorder Brain Disease Huntington’s disease Wilson’s disease Paraneoplastic encephalitis Encephalitis or other CNS infection (neurosyphillis) Tumor HIV encephalophaty Stroke Psychosomotor seizure CNS vasculitis • Vitamin B deficiency • Hyponatremia • Hepatic encephalopathy • Uremia • Hyperadrenalism • Hyper or Hypothyroidism (severe) • Acute intermittent porphyria

11. Drugs Causing Psychotic Symptoms • Antidepressants • anticholinergics, • Antiarrhythmics • Antihistamines • Ciprofloxacin • Antimalarials • antivirals, • Anticonvulsants • Corticosteroids • dopamine agonists • opioids, • sympathomimetics

12. Recommendation for Attending Physician • Regardless of etiology, acutely psychotic medical inpatients may require constant observation, restraints, and/or involuntary treatment. • Reassurance and education of the patient and the family about the symptoms and their cause(s), if known, are also helpful. • Unnecessary stimulation of the patient should be avoided (eg, repeated interviews by groups of trainees)

13. All nonessential medications should be discontinued or reduced in dosage if they are possible contributors. • Close collaboration between psychiatric and medical staff is necessary

14. Treatment • If the cause cannot be eliminated in medically ill patients with primary or secondary psychosis, antipsychotics is preferred • For short-term use, haloperidol is usually preferred in medically ill patients because of : • extensive experience with its use • Minimal side effects other than extrapyramidal ones • can be administered by mouth, intramuscularly (IM), or intravenously (IV) or as a liquid (eg, haloperidol, risperidone,

15. Treatment Consideration • Several antipsychotics can be given IM, this route is not practicable if many parenteral doses are required and IV haloperidol should be considered. • Most antipsychotics can be used in cardiac patients even after an acute myocardial infarction. • While antipsychotics rarely cause adverse hepatic reactions, there is no evidence that liver disease increases their risk of hepatotoxicity.

16. Since all antipsychotics are metabolized in the liver, they should be used more cautiously in patients with hepatic failure • Antipsychotics can lower seizure threshold, their use is not contraindicated in patients who are receiving anticonvulsants, but clozapine should be avoided. • In patients with diabetes mellitus or those who at high risk for the condition, antipsychotics are less likely to induce glucose intolerance and are therefore preferred

17. Conclusion • Psychosis in medically ill patient are common and can be found in general medical setting • There are many medical problems and drug that cause psychotic symptoms in medically ill patient • Determine the underlying causes and treat the patient with treatment recommendation • Antipsychotic still has the meaningful role in managing psychotic symptoms in medically ill patient

18. TerimaKasih Email : mbahndi@yahoo.com : @mbahndi