GANGGUAN CEMAS

ANXIETY DISORDER

By Dr. IBRAHIM PUTEH, SpKJ

N?

- Anamnese

ANSIETAS

- Pemeriksaan

Patologis ?
Cemas menetap
Gangguan fungsi e/c distress
Gejala ANS (+)
Komponen dari
: - Sakit fisik
: - Sakit Mental
Karakteristik
- Diffus, Unpleasant, unknown threatened, Berhubungan dgn ANS
Beda dgn rasa takut
- Cemas : Ancaman unknown, Internal, Vague, diffus
Berasal dari konflik
- Takut : Reality threatened, External
Non konflik
N T - GABA
- Serotonin
- Norephineprin

Stress ( ST )
Normal

- MPE
- Coping mekanisme

Sakit
S kalau ST

> MPE & CM

Eksternal
imbalance

Pressure dunia luar

Vs
Ego person

Internal

Impuls ( Dependence,

SAKIT

Agressive,
imbalance

Sexual )
Vs
Conscience ( Nurani )

GANGGUAN ANSIETAS
1.

Panic Disorder

- Agora Phobia (+)

- Agora Phobia ( - )

2.
3.
4.
5.
6.
7.
8.
9.
10.

Specific & Socio Phobia

OCD
Post Traumatic Stress Disorder
Acute Stress Disorder
GAD
AD due to General Medical Condition
AD NOS
Mixed Anxiety Depressive Disorder
Subtance Induced AD

Disorders Associated with Anxiety

Neurological disorders
Endocrine disturbances
Cerebral neoplasma
Pituitary dysfunction
Cerebral trauma and
Thyroid dysfunction
post concussive syndromes
Parathyroid dysfunction
Cerebrovascular disease
Adrenal dysfunction
Subarachnoid hemorrage
Pheocromocytoma
Migraine
Vilirization disorders of females
Encephalitis
Cerebral syphilis
Inflammatory disorders
Multiple sclerosis
Lupus erythematosus
Wilsons disease
Rheumatoid arthritis
Huntingtons disease
Polyarteritis nodosa
Epilepsy
Temporal arteritis
Systemic conditions
Deficiency states
Hypoxia
Vit B12 deficiency
Cardiovascular disease
Pellagra
Cardiac arrhythmias
Pulmonary insufficiency
Anemia

Miscellaneous conditions
Toxic conditions
Hypoglycemia
Alcohol and drug withdrawal
Carcinoid syndrome
Amphetamines
Systemic malignancies
Sympathomimetic agents
Premenstrual syndrome
Vasopressor agents
Febrile illness and chronic infections
Caffeine and caffeine withdrawal
Porphyria
Penicillin
Infectious mononucleosis
Sulfonamides
Posthepatitis syndrome
Cannabis
Uremia
Mercury
Arsenic
Idiopathic psychiatrist disorders
Phosphorus
Depression
Organophosphates
Mania
Carbon disulfide
Schizophrenia
Benzene
Anxiety disorders
Aspirin intolerance
Generalized anxiety
Panic attacks
Phobic disorders
Post traumatic stress disorders

Psychoanalytic Neuroses and Disorders in DSM-IV

Classic Neuroses

DSM-IV Classification

Anxiety

Generalized anxiety disorder

Phobic

Agoraphobia, specific and social

phobia

Obsessive-compulsive

Obsessive-compulsive disorder

Depressive

Dysthymic disorder

Hysterical (conversion)

Conversion disorder

Hysterical (dissociative)
disorder

Depersonalization

Hypochondriacal

Hypochondriasis

Paraphilic

Sexual disorder

Peripheral Manifestations of Anxiety

Diarrhea
Dizziness, light-headedness
Hyperhidrosis
Hyperreflexia
Hypertension
Palpitation
Pupillary mydriasis
Restlessness ( e.g pacing )
Syncope
Tachycardia
Tingling in the extremities
Tremors
Upset stomach (butterflies)
Urinary frequency, hesitancy, urgency

PANIC DISORDER AND AGORA PHOBIA

Panic
----- Spontan , singkat ( < 1 jam ), takut, cemas >>
Agoraphobia ----- Takut sendiri di tempat ramai
NT
Panicogen

: Norephinephrin, GABA, Serotonin

: CO2, Laktat

Gambaran klinis
Psikis

: Sulit bicara, memory terganggu, depresi

Depersonalisasi saat serangan

Associated symptom --- depresi

Agoraphobia Sering dengan - PHK
- Marital discord
- NAPZA abuse

THERAPY
Pharmacotherapy
Anti depressant

- Tri / tetracyclic
- MAO
- SSRI

Anti anxietas

- Benzodazepin
- Buspar ( Azospirone )

Anafranil

= 10 mg dinaikkan gradually 2/3 hari 10 mg

lama terapi 8 12 mgg

SSRI

= 2 4 mg ID dinaikkan 2 4 mg / 2 4 h
Full dose 20 mg / h

Criteria for Agoraphobia

Note : Agoraphobia is not a codable disorder. Code the specific disorder in which
the agoraphobia occurs (e.g. panic disorder with agoraphobia or agoraphobia
without history of panic disorder).
A.
Anxiety about being in places or situations from which escape might be
difficult (or embarrassing) or in which help may not available in the event of
having an unexpected or situationally predisposed panic attack or panic
like symptom. Agoraphobia fears typically involve characteristic cluster of
situations that include being in outside the home alone; being in a crowd or
standing in a line; being on the bridge; and traveling in a bus, train or auto
mobile.
Note : Consider the diagnosis of specific phobia if the avoidance is limited to
one or only a few specific situations, or social phobia if the avoidance is
limited to social situations.
B.
The situation are avoided (e.g. travel is restricted) or else are endured with
marked distress or with anxiety about having a panic attack or panic-like
symptom, or require the presence of a companion.
C.
The anxiety or public avoidance is not better accounted for by another
mental disorders, such as social phobia (e.g. avoidance limited to social
situations because of fear of embarrassment), specific phobia
(e.g. avoidance limited to a single situation like elevators), obsessive
compulsive disorder (e.g. avoidance of dirt in someone with obsession about
contamination), post traumatic stress disorder (e.g. avoidance of stimuli
associated
with a severe stressor), or separation anxiety disorder (e.g. avoidance of
leaving home or relatives).

Diagnostic Criteria for Panic Attack

Note : A panic attack is not a codable disorder. Code the specific diagnosis in
which the panic attack occurs (e.g. panic disorder with agoraphobia)
A discrete period of intense fear or discomfort, in which four (or more) of the
following symptom developed abruptly and reached a peak within 10
minutes.
1.
Palpitations, pounding heart, or accelerated heart rate
2.
Sweating
3.
Trembling or shaking
4.
Sensation of shortness of breath or smoothering
5.
Feeling of choking
6.
Chest pain or discomfort
7.
Nausea or abdominal distress
8.
Feeling dizzy, unsteady, lightheaded, or faint
9.
Derealization (feeling of unreality) or depersonalization (being detached
from
oneself)
10. Fear of loosing control or going crazy
11. Fear of dying
12. Paresthesias (numbness or tingling sensations)
13. Chills or hot flushes

SPECIFIC PHOBIA AND SOCIAL PHOBIA

Incidence

Wanita 2 x > Pria

Specific Phobia >> Social Phobia
Social Phobia 3/100 orang ( usia 5 35 thn )

Specific Phobia Objek khusus

c/ - Binatang
- Ketinggian
- Kematian dll

Treatment :
Insight

Oriented Psychotherapy
Hypnosis Bangkitkan fobia objek
Social phobia Pharmacotherapy
- Anti Ansietas
- Anti Depressan

Diagnostic Criteria for Specific Phobia

A.

Marked and persistent fear that is excessive or unreasonable, cued

by the
presence or anticipation of a specific object or situation (e.g. flying,
heights,
animals, receiving injection, seeing blood)

B.

Exposure to the phobic stimulus almost invariable provokes an

immediate
anxiety response, which may take the form of a situationally bound
or situationally predisposed panic attack.
Note : in children, the anxiety may be expressed by crying, tantrums,
freezing, or clinging.

C.

The person recognizes that the fear is excessive or unreasonable.

Note : in children, this feature may be absent.

D.

The phobic situation(s) is avoided, or else endured with intense

anxiety or
distress.

E.

The avoidance, anxious anticipation, or distress in the feared situation(s)

interferes significantly with the persons normal routine, occupational
(or academic) functioning, or social activities or relationship with others, or
there is marked distress about having phobia.

F.

In individual under age 18 years, the duration is at least 6 months.

G.

The anxiety, panic attacks, or phobic avoidance associated with the specific
object or situation are not better accounted for by another mental disorder,
such as obsessive-compulsive disorder, posttraumatic stress disorder,
separation anxiety disorder, social phobia, panic disorder with agoraphobia,
or agoraphobia without history of panic disorder.

Specify type :
Animal type
Natural environment type (e.g. heights, storms, and water)
Blood, injection, injury type
Situational type (e.g. planes, elevators, enclosed places)
Other type (e.g. phobic avoidance of situation that may lead to choking,
vomiting,
or contraction of illness)

Diagnostic Criteria for Social Phobia

A.

A marked and persistent fear of one or more social or performance

situations in which the person is exposed to unfamiliar people or to
possible
scrutiny by others. The individual fears that he or she will act in a way
(or show anxiety symptoms) that will be humiliating or embarrassing.
Note : in children, there must evidence of capacity for age-appropriate
social relationships with familiar people and the anxiety must occur in
peer
setting, not just in interaction with adults.

B.

Exposure to the feared social situation almost invariably provokes

anxiety,
which may take the form of a situationally bound or situationally
predisposed
panic attack.
Note : in children, the anxiety may be expressed by crying, tantrums,
freezing, or shrinking from social situation with unfamiliar people.

C.

The person recognizes that the fear is excessive or unreasonable.

Note : in children, this feature may be absent.

D.

The feared social or performance situations are avoided, or else endured

with intense anxiety or distress.

E.

The avoidance, anxious anticipation, or distress in the feared social or

performance situation(s) interferes significantly with the person normal
routine, occupational (academic) functioning, or social activities or
relationships with others, or there is marked distress about having the
phobia.

F.

In individual under age 18 years, the duration is at least 6 months.

G.

The fear or avoidance is not due to direct psychological effects of a

substance (e.g. a drug of abuse, a medication) or a general medical
condition, and is not better accounted by another mental disorder (e.g.
panic disorder with or without agoraphobia, separation anxiety disorder,
body dysmorphic disorder, a pervasive developmental disorder, or
schizoid
personality disorder)

H.

If a general medical condition or other mental disorder is present, the

fear in
criterion A is unrelated to it, e.g. the fear is not of stuttering, trembling in
Parkinson's disease, or exhibiting abnormal eating behavior in anorexia
nervousa or bulimia nervousa.

Specify if :
Generalized : if the fear include most social, situations (also consider the
additional diagnose of avoidant personality disorder.

OBSESSIVE COMPULSIVE DISORDER

( OCD )

OBSESSI

: Keadaan dimana pikiran bertahan pada satu hal

( berulang-ulang )

KOMPULSI

: Tingkah laku disadari, berulang, menetap e/c obsessi

Obsessi
Kompulsi

Ansietas meningkat
Ego Dystonik

Live time prevalence 2 3 %

Therapy ( lihat diagram )

Diagnostic Criteria for Obsessive-Compulsive Disorder

A.
Either obsessions or compulsions:
Obsessions as defined by (1), (2), (3) and (4)
(1) Recurrent and persistent thought, impulses or images that are experienced
at some time during the disturbance as intrusive and inappropriate and cause
marked anxiety or distress
(2) The thought, impulses or images are not simply excessive worries about
real-life problems
(3) The persons attempts to ignore or suppress such thought, impulses, or images
to neutralize them with some other thought or action
(4) The person recognizes that the obsessional thoughts, impuls or images are
a product of his or her own mind (not imposed from without as in thought
insertion)
Compulsions as defined by (1) and (2)
(1) Repetitive behavior (e.g. hand washing, ordering, checking) or mental acts
(e.g. praying, counting, repeat words silently) that the person feels driven to
perform in response to an obsession, or according to the rules that must be
applied rigidly
(2) The behavior of mental acts are aimed at preventing or reducing distress or
preventing some dreaded event or situation; however, these behavior or
mental acts either are not connected in a realistic way with what they are
designed to neutralize or prevent, or are clearly excessive

B.

At some point during the course of the disorder, the person has recognized that
the obsessions or compulsions are excessive or unreasonable.
Note : this does not apply to children
C.
The obsession or compulsion cause marked distress: are time-consuming
( take more than an hour a day ): or significantly interfere with the persons
normal routine, occupational (or academic) functioning or usual social activities
or relationships
D.
If another axis I disorder is present, the content of the obsession or compulsion
is not restricted to it (e.g. preoccupation with food in the presence of an eating
disorder, hair pulling in the presence of tricothilomania
concern with appearance of the body dysmorphic disorder : preoccupation
with drugs in the presence of a substance use disorder : preoccupation with
having serious illness in the presence of hypochondriasis : preoccupation
with sexual urges or fantasy in the presence of paraphilia : or guilty
ruminations in the presence of major depressive disorder)
E.
Not due to direct effects of a substance (e.g. a drug of abuse, a medication)
or a general medical condition.
Specify if :
With poor insight : if for most of the time during the current episode, the person
does not recognized that the obsessions and compulsions are excessive or
unreasonable

SRI
No change

MAOI

If panic
Present

Partial change

Switch
SRI
Partial or
No change

Combination
treatment
If anxious

Buspirone

if depressed

if tics, delusional

Lithium

Neuroleptic

Fenfluramine

Still ill?
If suicidal

ECT

Novel
Treatments
e.g, antiandrogen

Failed Plus
2SRis suicidal
3 combinations incapacitated
ECT
Behavior treatment

Psychosurgery

POST TRAUMATIC STRESS DISORDER ( PTSD )

&
ACUTE STRESS DISORDER ( ASD )

PTSD

: - Pengulangan pengalaman trauma via mimpi / pikiran

- Mencegah mengingat kembali trauma dan reaksi tumpul thd
trauma
- Bangkitan berlebihan yang menetap

PTSD Hubungan erat dengan - Anxiety

- Depressi
- Gangguan kognitif

ASD Keluhan symptom muncul setelah 4 minggu

Peristiwa traumatic dan hilang dalam 2 hari s/d 4 minggu
Incidence

13%

Predisposisi
1.
Childhood trauma
2.
Kepribadian borderline, paranoid, dependent, and antisocial trait
3.
Inadequate support system
4.
Rapuh terhadap gangguan mental
5.
Kehidupan penuh stress
6.
Alkoholic
Prognosa baik bila
Therapy
1.
Sakit singkat
Pharmacotherapy
2.
Fungsi premorbid baik
- Sedative, Hypnotic, Antidepressant
3.
Strong social support
Psychotherapy
4.
Rapid onset of the symptom
- Behavior, Cognitive, Hypnosis
5.
Tidak ada gangguan psikiatrik,
drug abuse dan sakit medis

ANXIETY DISORDER DUE TO

GENERAL MEDICAL CONDITION

ETIOLOGI
- Kondisi medis seperti hyper / hypothyroid , defisiensi vit B12,
Pheochromacytoma

DIAGNOSA ( lihat lamp. )

THERAPY
- Obati kondisi medis
- Anti ansietas
- Anti depressan k/p

k/p

Diagnostic Criteria for Anxiety Disorder Due to a General Medical

Condition
A.
B.

C.

D.
E.

Prominent anxiety, panic attack, obsessions or compulsions predominate

the clinical picture
There is evidence from the history, physical examination, or laboratory
findings that the disturbance is the direct physiological consequence of a
general medical condition
The disturbance is not better accounted for by another mental disorder
(e.g. adjustment disorder with anxiety, in which the stressor is a serious
general medical condition)
The disturbance does not occur exclusively during the course of delirium
The disturbance causes clinically significant distress or impairment in
social,
occupational, or other important areas of functioning

Specify if
With generalized anxiety
: if excessive anxiety or worry about a number
of
events or activities predominates in the clinical presentation
With panic attack
: if panic attack predominate in the clinical presentation
With obsessive-compulsive symptom : if obsessions or compulsions
predominate in the clinical presentation

SUBSTANCE INDUCED ANXIETY DISORDER

ETIOLOGI
Substance

Simphatomimetic
- Amphetamin
- Cocaine
- Caffeine
Serotonergic
- LSD / MDMA

DIAGNOSA
- Cemas menetap, panic attack
- Ketergantungan zat atau keadaan toxic atau tidak

TERIMA KASIH