PENANGANAN EFEK PSIKIS

AKIBAT TRAUMA FISIK

Rh Budhi Muljanto
PENANGANAN EFEK PSIKIS
AKIBAT TRAUMA FISIK
Definition of Trauma
Psychological 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 Trauma
Bencana alam
Penculikan
Kekerasan di sekolah
Kekerasan kehidupan
Kekerasan di
masyarakat
Terorisme/perang
Korban tindakan
kriminal
Rudapaksa fisik
Rudapaksa Sexual
Percobaan
Pembunuhan
Tindakan medis
Kecelakaan
Percobaan Bunuh diri
Penelantaran yang
sangat menyakitkan
TBI in the United States

50,000
Deaths
235,000
Hospitalizations
1,111,000
Emergency Department Visits
??? Receiving Other Medical Care or No Care
At least
1.4 million
TBIs occur in the
United States
each year.*
* Average annual numbers, 1995-2001
CDC, 2006
4%
17%
57 million living
With TBI Worldwide
Traumatic Brain Injury (TBI)
Neurobiological Injury

Traumatic Event

Chronic Medical Illness

TBI as Neurobiological Injury
Primary effects of TBI
Contusions, diffuse axonal injury
Secondary effects of TBI
Hematomas, edema, hydrocephalus, increased
intracranial pressure, infection, hypoxia,
neurotoxicity, inflammatory response, protease
activation, calcium influx, excitotoxin & free
radical release, lipid peroxidation, phospholipase
activation
Can affect serotonin, norepinephrine,
dopamine, acetylcholine, and GABA systems
TBI-associated Disability
Postconcussive Symptoms

Cognitive
Physical: sensory and motor
Emotional

Vocational
Social
Family
Neuropsychiatric Sequelae
Delirium
Depression / Apathy
Mania
Anxiety
Psychosis
Cognitive Impairment
Aggression, Agitation, Impulsivity
Postconcussive Symptoms
Neuropsychiatric Evaluation and
Treatment: Etiologies
Psychiatric Neurologic/Medical Social


Premorbid Neurologic illness Social, family, vocation
Psych disorders & sxs. Lesion location, size, Rehabilitation situation
Personality traits pathophysiology and stressors
Coping styles Other medical illness Functional impairment
Substance Abuse Other indirect sequelae Medicolegal
Medication side effects (e.g., pain, sleep disturb)
& interactions Medication side effects
Psychodynamic sig. & interactions
of neurologic illness
Family psych. history

Roy-Byrne P, Fann JR. APA Textbook of Neuropsychiatry, 1997
Neuropsychiatric Evaluation and
Treatment: Workup
Psychiatric Neurologic/Medical Social


Psychiatric history & Medical history and Interview family, friends,
examination physical examination caregivers
Neuropsychological Appropriate lab tests Assess level of care &
testing e.g., CBC, med blood supervision available
Psychodynamic signif. of levels, CT/MRI, EEG Assess rehab needs
neuropsychiatric sxs., Medication allergies & progress
disability and treatments

Neuropsychiatric Evaluation and
Treatment: Follow-up
Psychiatric Neurologic/Medical Social


Frequent pharmacologic Physical signs & sxs. Rehabilitation
monitoring Physiologic response Maximize support
Psychotherapy (e.g., vital signs) system
Intermittent cognitive Appropriate lab tests
assessments (e.g., CBC, medication
Support Groups blood levels, EEG)

Neuropsychiatric History
Psychiatric symptoms may not fit DSM-IV criteria
Focus on functional impairment
Document and rate symptoms
Explore circumstances of trauma
LOC, PTA, hospitalization, medical complications
Subtle symptoms - may fail to associate with
trauma
How has life changed since TBI?
Thorough review of medical and psychiatric sxs.
Talk with family, friends, caregivers
Assess level of care and supervision available
Assess rehabilitation needs and progress

Threat/Stress
Hypothalamus
(CRH, AVP)
Modulates, inhibits
HPA Axis
Adrenal Cortex
(Cortisol)
-Cardiovascular adaptation
-Vigilance
-Catabolism
-Immune suppression
-Growth suppression
Mediates
Anterior Pituitary
(ACTH)
THE HYPOTHALAMIC/PITUITARY/ADRENAL AXIS
Traumatic
event
cues
TERAPI
Terapi pilihan: Psikoterapi

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

Mengembalikan kemampuan pasien
mengendalikan emosinya







Neuropsychiatric Treatment
Use Biopsychosocial Model
Treat maximum signs and symptoms with
fewest possible medications
TBI patients more sensitive to side effects
START LOW, GO SLOW
May still need maximum doses
Therapeutic onset may be latent
Medications may lower seizure threshold
Medications may slow cognitive recovery
Monitor and document outcomes
Few randomized, controlled trials
KONSELING
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 KONSELING
Merawat & menjaga keswa seseorang
Mengembalikan fungsi seseorang
Menyelesaikan masalah seseorang
Menemukan cara lain pemecahan masalah
Mempelajari teknik-teknik menghadapi dan
menyelesaikan masalah
Memberikan kemampuan pemahaman diri
Membangun kemampuan mengambil keputusan
Menyediakan informasi
KONSELING
Berfokus/spesifik
kebutuhan/masalah
Berfokus pada tujuan
Proses timbal balik
Memperhatikan situasi
interpersonal
Mengajukan pertanya
an, menyediakan
informasi,
mengembangkan
rencana tindakan
Mengarahkan
/menyarankan
Menasehati
Obrolan
Interogasi
Wawancara
Pengakuan
Curhat
Doa
harapan
SYARAT MENJADI
KONSELOR/FASILITATOR
1. Menerima klien
apa adanya
2. Bersifat optimis
3. Mampu simpan
rahasia
4. Sansitif menilai
5. Mampu beri
informasi
6. Fleksibel
7. Dpt menghargai
orang lain
8. Mampu jadi tem-
pat bergantung
9. Terbuka dan Jujur
10.Bersikap tidak
menilai
11.Percaya diri
12.Punya rasa humor
13.Pendengar yg baik
14.Terampil dlm
membantu
15.Dapat 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
Suara
Penampilan
Perilaku Tubuh
Reaksi Fisiologis
Yang boleh dilakukan (DOs)
Dekati mereka secara aktif
Dengarkan mereka
Empati, hindari simpati
Hargai martabat mereka
Terima dan hargai pandangan mereka
tentang masalahnya
Ketahui kebutuhan mereka untuk privacy
dan confidential
Jamin perawatan yang berkelanjutan
Yang tidak boleh dilakukan (DONTs)

Jangan paksakan dukungan dan bantuan
pada mereka
Jangan interupsi mereka bila mereka sedang
menyatakan emosinya
Jangan mengasihati mereka
Jangan menghakimi mereka
Jangan sebarkan rumor
Jangan melabel mereka dengan gangguan
psikiatri ( lebih baik rujuk ke dokter atau
profesi keswa)
EMPATI > < SIMPATI
Saya dapat memahami apa
yang terjadi pada anda
Saya dapat memahami
bahwa anda merasa marah
terhadap apa yang terjadi
pada anda
Saya 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 anda
Saya juga marah dan kita
akan mengatasinya
bersama-sama
Jangan takut, Saya disini
untuk membantu anda
apapun yg anda butuhkan
Saya mohon maaf sama
anda, jangan khawatir
semuanya akan menjadi
lebih baik
CARA MEMAHAMI PENGALAMAN KLIEN
1. Menerima klien apa adanya
2. Membina hubungan baik dan slg percaya
3. Dengarkan dg seksama
4. Perhatikan 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
baik
5.Tanyakan lebih rinci sehingga anda
memahaminya. Kadangkala perlu waktu
untuk mengungkap perasaannya
6.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 jelas
7.Bantu mereka agar berbicara tentang
perasaannya
8. Bersama-sama membicarakan jalan keluar
yang dapat dilakukan
9. Jangan menghakimi
10. Jangan 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 perbaikan
11. Jangan melanggar janji kerahasiaan
BANTU PEMECAHAN MASALAH
1. 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
MASALAH
Diskusikan tiap masalah dan bantu mencari jalan
keluar yg berbeda
Buat rencana dan jadwalkan waktu untuk
melakukan
Gali kemampuannya untuk memecahkan masalah
Bl mereka tak ada ide anda ajukan usul
3. 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 dimengerti
Tanyakan apakah mereka setuju dg kesimpulan
yg dibuat
Diskusikan apa saja yg hrs dilakukan

4. LANGKAH YG HRS DILAKUKAN
Bantu mencari cara yg dpt dilakukan
Diskusikan perasaan mereka sp mereka dpt
memutuskan cara yg dianggap cocok
5. BERI KEPASTIAN BHW MEREKA MAMPU MELAKUKAN

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

TERIMA KASIH
Table 16.5-5 DSM-IV-TR Diagnostic Criteria for Acute Stress Disorder
A.The person has been exposed to a traumatic event in which both of the following were present:
A. 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
B. the person's response involved intense fear, helplessness, or horror
B.Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following
dissociative symptoms:
A. a subjective sense of numbing, detachment, or absence of emotional responsiveness
B. a reduction in awareness of his or her surroundings (e.g., being in a daze)
C. derealization
D. depersonalization
E. dissociative amnesia (i.e., inability to recall an important aspect of the trauma)
C.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.
D.Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities,
places, people).
E.Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration,
hypervigilance, exaggerated startle response, motor restlessness).
F.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.
G.The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic
event.
H.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 Disorder
A.The person has been exposed to a traumatic event in which both of the following were present:
A. 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
B. the person's response involved intense fear, helplessness, or horror.
Note: In children, this may be expressed instead by disorganized or agitated behavior.
B.The traumatic event is persistently reexperienced in one (or more) of the following ways:
A. 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.
B. recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.
C. 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.
D. intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
E. physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
C.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:
A. efforts to avoid thoughts, feelings, or conversations associated with the trauma
B. efforts to avoid activities, places, or people that arouse recollections of the trauma
C. inability to recall an important aspect of the trauma
D. markedly diminished interest or participation in significant activities
E. feeling of detachment or estrangement from others
F. restricted range of affect (e.g., unable to have loving feelings)
G. sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)
D.Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
A. difficulty falling or staying asleep
B. irritability or outbursts of anger
C. difficulty concentrating
D. hypervigilance
E. exaggerated startle response
E.Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.
F.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 months
Chronic: if duration of symptoms is 3 months or more
Specify if:
With delayed onset: if onset of symptoms is at least 6 months after the stressor