Case Presentation

Aggression Module
Scenario 2
Group 2

Ribka Melisa E. AnggraenyC 11111 804

Joel Cahadi PhilipsC 11111 817
Norhani Azura binti MashhorC 11111 836
Siti Aishah binti KhairudinC 11111 849
Nurul Farhana binti HanifC 11111 852
Nur Lyna binti RidzuanC 11111 865
Siti Fatimah binti OthmanC 11111 881
Hardiyanty Agriyani PutriC 11111 892
Andi RaynaldiC 11111 900
Andi Alfisya Bayu EkaputraC 11109 770
Marhama FitrianiC 11109 814
Muliana Khaerunniza .N.C 11109 890

Scenario & Keywords

Seorang perempuan berusia 20 tahun

diantar oleh keluarganya ke psikiater karena

mengamuk dan tidak bisa berhenti bicara,
Hal ini sudah dialami sejak 2 minggu lalu.
Pasien juga tidak bisa berhenti bergerak,
tertawa-tawa, berdandan sangat menor
dan menganggap dirinya seorang artis.
Ketika ditanya pasien mengaku kadangkadang mendengar suara yang memuji
dirinya. Gejala-gejala ini pernah dialami 2
bulan sebelumnya.

Questions
What
What
What
What
What

is the definition of aggresion?

are the classification of aggression?
are the etiologies of aggression?
is the mechanism of aggression?
is the relation between the age & sex
and the symptoms?
What is the cause of hallucination?
Additional Anamnesis

Aggression
Behaviour that directed by an organism towards
a target resulting in a damage

Aggression Classification
Predatory Aggression
Inter-Male Aggression
Fear-Induced Aggression
Irritable Aggression
Maternal Aggression
Sex-related Aggression

Aggression Etiologies
First Theory:
Aggression
caused
by
the
disturbance of amygdala nucleus
that correlated with the emotion
central.
Second theory
Aggression caused by lesion in
pre-frontal cortex.

AMYGDALA
Function:
Enthusiasm
Autonomic control (response related with
fear)
Emotional response
Hormonal secretion
Location:
Amygdala is an almond-like mass with the
core located far inside the temporal lobe,
medial to hypothalamus and near the
hippocampus.

amygdala

Aggression Mechanism
the exact mechanism of aggression is still unknown
until now. However there are some theories that
explain about how aggression occurred:
Noradrenergic Hyperfunction
Dopaminergic Neurotransmitter
Opiate Neurotransmiter
Hypothalamicpituitaryadrenal axis

Sumber
Agitation in the ICU: part one Anatomical and physiologic basis for the
agitated state David Crippen. 1999. University of Pittsburgh Medical Center, Associate
Director, Department of Emergen y and Critical Care Medicine, St. Francis Medical
Center, Pittsburgh, PA 15201, USA

the relation between the age & sex

and the symptoms
Based on the epidemiology studies, found that :
- Schizophrenia
age : 16-45 years old
Frequency : man and women is same
- Mania
Age : late teens or 20 years old
Frequency : man and woman is same
Source : www.mayoclinic.com

Causes of Hallucination
reduced brain integration
social isolation
high levels of emotionality

http://www.healthyplace.com/thought-disorders/schizophrenia-articles/auditory-hallucinati
ons-whats-it-like-hearing-voices/#story

Additional Anamnesis
For an accurate diagnosis, we need to find out
about certain things from the patient or the
patients family, which are :
Previous disease, medication, and family
history (specifically mental disorder-related)
Daily activity
Patients social activity ( associating with
friends and family)

Example
Hows the mood and affect?
Hows the psychomotoric function?
Hows the patients thinking process?
Is the condition ever happened before?
What are the patients previous diseases?
What are the patients previous medications?
Are the daily activities still done by the

patient?
Hows the hallucination characteristic?
Is the patient socializing with friends or
family?

Mania with
psychotic
disorder

Acute
Schizoaffectiv
schizophrenic
e bipolar
-like
disorder
psychotic
disorder

Female, 20 y.o

(M>F)

Onset
mengamuk : 2
weeks ago

Onset gejala :
2 months ago

Relapse of
symptoms

Hyperactive

(accompanied
by depression)

Grandiose
delusion

(or any other

type of
delusions)

(or any other

type of
delusions)

Auditory

Mania
An episode of definite affective-increased on a

person.
It is abnormal, settled, expansive, and
irritable.
Mania symptoms include fast speech, rapid
thinking, decrease need for sleep, and
increase interest on one goal.
Also shown irritable behaviour, aggression,
sensitive, hyperactive, and grandiose
delusion.

Mania Diagnostic Guide

DSM IV
A distinct period of abnormal and persistent
elevated, expansive, or irritable mood, lasting for
at least 1 week
At least 3 points from below points:
1. Grandiosity
2. Decreased Need for Sleep
3. More Talkative than usual
4. Flight of Ideas
5. Hard to Pay Attention
6. Increased in goal-directred activity
7. Excessive involvement in harmful activities

 Symptoms dont meet criteria for mixed episode

The mood disturbance is sufficiently severe to cause

marked impairment in occupational functioning or in

usual social activities or relationships with others, or
to necessitate hospitalization to prevent harm to self
or others, or there are psychotic features.
The symptoms are not due to the direct
physiological effects of a substance (e.g., a drug of
abuse, a medication or other treatment) or a general
medical condition (e.g., hyperthyroidism)
http://www.mental-health-today.com/bp/man.htm

PPDGJ III
F30.1 : Mania without Psychotic Symptoms
Episode at least 1 week, and severe enough
to distract the social-activity.
Affect-shift had to be accompanied with the
increase of energy, and later cause the overincrease of activity, rapid and more speech,
decreased need for sleep, grandiose idea and
over-optimistic.
Maslim,Rusdi. 2001.Diagnosis Gangguan Jiwa, Rujukan Ringkas
PPDGJ III.Jakarta : PT Nuh
Jaya. p61

F30.2 : Mania with Psychotic Symptoms

Clinical Features more severe than F30.1 ( Mania
without psychotic symptoms)
The increase of self-esteem or grandiose idea
could develop into grandiose delution, irritability
and suspect of persecution delution. Delusion and
hallucination match with the affective-state
(mood-congruent).
Maslim,Rusdi. 2001.Diagnosis Gangguan Jiwa, Rujukan Ringkas PPDGJ
III.Jakarta : PT Nuh
Jaya. p61

Symptoms explanation
Display general: excited, talkative, droll, hyperactivity, and
showed psychotic symptoms.

Natural feeling: Easily offended, not easily frustrated, irritable

and attack, emotionally unstable, can be quickly changed and
happy to depressed in a while.

How to speak: His speech is difficult to cut, loud volume,

springboard ideas (flight of ideas), a loose association,
decreased concentration, can be incoherent and neologisms
that it is difficult to distinguish from schizophrenia patients.

Widya, Surya. Simposium Sehari Kesehatan Jiwa Dalam Rangka Menyambut Hari Kesehatan
Jiwa Sedunia : Gangguan Afektif. 27 Oktober 2007. Diakses 6 Februari 2008

Impaired perception: 75% of patients

experiencing delusions mania, usually
associated with wealth, extraordinary
ability, strength or prowess incredible.
Sometimes there are delusions and
hallucinations are chaotic and harmonious.

Disruption of mind: Mind patients filled

with excessive confidence, feel great. They
are easily distracted, very productive and
out of control.

Widya, Surya. Simposium Sehari Kesehatan Jiwa Dalam Rangka Menyambut Hari
Kesehatan Jiwa Sedunia : Gangguan Afektif. 27 Oktober 2007. Diakses 6
Februari 2008

Impaired sensorium and cognitive function: There is

a slight disturbance in sensorium and cognitive
function, sometimes the answers do not fit the
question although there is no interference and no
interference orientation memory.

Impaired self-control: About 75% of patients with

mania liked threatened and attacked. They could not
control myself to not do things that harm offended or
angry.

Reliability: mania patients often lie when providing

information, Due to lie and deceive is normal for
them.

Widya, Surya. Simposium Sehari Kesehatan Jiwa Dalam Rangka

Menyambut Hari Kesehatan Jiwa Sedunia : Gangguan Afektif. 27
Oktober 2007. Diakses 6 Februari 2008

Treatment of
Mania
Mood stabilizers:

lithium (0.61.2 mEq/L)

carbamazepine (612 mg/L)
valproate (50125 mg/L)
Anticonvulsants:

gabapentine
topiramate
lamotrigine

 Agitated or psychotic patient

coadministartion of :
antipsychotics of second generation
(olanzapine, risperidone)
benzodiazepines (lorazepam,
clonazepam)
ECT

http://manicdepression.allsymptoms.net/
http://www.webmd.com/bipolar-disorder/guide/bipolar-d
isorder-treatments-bipolar-mania

Prognosis

differ by current age or sex

onset in childhood or adolescence appears to

have more long-term morbidity than does

later onset
Patients who switch directly from one pole
(mania or depression) to the other also tend
to have longer and more frequent episodes
than do patients who experience discrete
episodes of mania or depression

http://www.medscape.org/viewarticle/487928_2

THANK YOU VERY

MUCH!