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PENANGANAN EFEK PSIKIS AKIBAT trauma fisik Definition of trauma Psychological trauma is generally seen as the reaction following exposure to an overwhelming experience that is out of control. At least 1. Million TBIs occur in the United States each year.
PENANGANAN EFEK PSIKIS AKIBAT trauma fisik Definition of trauma Psychological trauma is generally seen as the reaction following exposure to an overwhelming experience that is out of control. At least 1. Million TBIs occur in the United States each year.
PENANGANAN EFEK PSIKIS AKIBAT trauma fisik Definition of trauma Psychological trauma is generally seen as the reaction following exposure to an overwhelming experience that is out of control. At least 1. Million TBIs occur in the United States each year.
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
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