Curriculum Vitae dr.Andri,SpKJ,FAPM
Lahir : Tangerang, 19 Desember 1978
•Pendidikan formal :
– Dokter : FKUI Lulus 2003
– Psikiater : FKUI lulus 2008
•Pendidikan tambahan :
– 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
– Pengakuan sebagai Fellow Academy of Psychosomatic Medicine (FAPM) : 18
– IDI, PDSKJI, American Psychosomatic Society, Academy of Psychosomatic Medicine
•Jabatan saat ini
– Dosen Psikiatri di FK UKRIDA, Jakarta
– Kepala Klinik Psikosomatik Omni Hospital, Alam Sutera
– Ketua Sub Kredensial Komite Medik RS OMNI Alam Sutera
– Kepala Unit Riset FK UKRIDA
Psychosis in Medically Ill Patient
Division of Psychiatry
Universitas Kristen Krida Wacana (UKRIDA)
Arjuna Utara no.6 Jakarta Barat 11510
• Are psychiatric symptoms attributable to a
primary psychiatric syndrome?
Or are they secondary to medical disease, substance
use or medication intoxication?
Diagnosis and Assessment
Psychotic symptoms in a medically hospitalized patient fall into
one of three possibilities :
1.Primary psychiatric illness
- New-onset or an acute exacerbation of psychiatric illness associated
– Psychosis due to a general medical condition (systemic or brain-
– Substance induced psychosis
– Medication-induced psychosis
1.Secondary on Primary
– A patient with a primary psychotic disorder has psychosis unrelated
to his or her primary psychotic disorder
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.
Clinical Case (2)
• Three weeks after the last consultation, patient
started to experience auditory and visual
• 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
Diagnostic criteria for 293.xx Psychotic Disorder Due to . . . [Indicate the General
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
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.
• Cognitive function and level of
consciousness are relatively
• Focal neurological signs are
• Hallucinations are most often
auditory, delusions tend to be
• Thought disorder may be
• Incontinence is usually absent,
• Vital signs are usually normal
• 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
• Laboratory Evaluation
– Complete blood count
– Electrolytes including calcium and phosphate
– Serum urea nitrogen/creatinine
– Liver function tests
– HIV Test
– Vitamin B12 and folate
– Serum Cortisol level
– Urine cultures
– Blood cultures
• Brain Imaging
Recommendation for Attending
• Regardless of etiology, acutely psychotic
medical inpatients may require constant
observation, restraints, and/or involuntary
• 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
• All nonessential medications should be
discontinued or reduced in dosage if they are
• Close collaboration between psychiatric and
medical staff is necessary
• 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,
• Several antipsychotics can be given IM, this route
is not practicable if many parenteral doses are
required and IV haloperidol should be
• Most antipsychotics can be used in cardiac
patients even after an acute myocardial
• While antipsychotics rarely cause adverse hepatic
reactions, there is no evidence that liver disease
increases their risk of hepatotoxicity.
• Since all antipsychotics are metabolized in the liver,
they should be used more cautiously in patients with
• 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
• 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
• Determine the underlying causes and treat
the patient with treatment recommendation
• Antipsychotic still has the meaningful role in
managing psychotic symptoms in medically ill
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