Anxiety Disorder

(Gangguan Cemas)

Ronny T Wirasto, MD
Psychiatrist
Consultation Liaison Psychiatry Division
Dept of Psychiatry
Faculty of Medicine, Gadjah Mada University
2011
“miR-138-2, miR-148a, and miR-
488 repress (30%–60%) several
candidate genes for panic
disorder”
BIOL PSYCHIATRY 2011;69:526–533
2011 Society of Biological Psychiatry
 Learning Objectives
After completing this session, the students should
be able to :
1. Understand the neuro-psycho-pathology of
anxiety disorder
2. Conclude the relation between psychological and
environmental factors with anxiety disorder
3. Understand the characteristic of anxiety disorder
4. Understand the management of anxiety disorder
 Topics :

• Psycho-physiology
• Etiology
• Diagnosis
• Management
Psychophysiology

• STRESS
• NORMAL ANXIETY
• ANXIETY DISORDERS
• Stress
– A reaction to a situation, not the situation itself
– the arousal, both physical and mental, to
situations or events that we perceive as
threatening or challenging
• Eustress is positive stress occurs when your
level of stress is high enough to motivate you
to move into action to get things
accomplished
• Distress is Distress or negative stress occurs
when your level of stress is either too high or
too low and your body and/or mind begin to
respond negatively to the stressors
 Normal anxiety
• Anxiety is normal for the infant who is
threatened by separation from parents or by
loss of love
– for the children on their first day in school,
– for adolescents on their first date
– for adults when they think about old age and
death
– for anyone who is faced with illness
 Anxiety Disorder
• an inappropriate response to given stimulus
based on its intensity or its duration
• Prolonged Anxiety
• Involved :
– Physical Responses
– Psychological Responses (coping mechanism)
– Social Responses
 Etiology - Psychophysiopathology

• Biology
• Psychology
• Social-environment

Threatening!!!!
• Gene expression :
– 5-GGGCCTACTGTGGCTACTCA-3
– 5-GGCCCTTTTTCCAGGTCTG-3
• Biology : GABA and serotonin
• Diathesis Stress Model
• Individuals inherit tendencies to express certain traits
or behaviors, which are then expressed or activated
under conditions of stress.
• Psychodynamic Model
• mental mechanisms
• emphasis on childhood experiences
• emphasis on unconscious motives
• Id, Ego, Superego
• Anxiety is a signal that the ego’s controls are at risk of being
overcome by the id or the superego.
Diagnosis & Treatment
 Types Of Anxiety
• Generalized Anxiety Disorder
• Social Anxiety
• Post Traumatic Stress Disorder
• Obsessive Compulsive Disorder
• Phobic Disorders
• Panic Disorder with or without agoraphobia
• Atypical Anxiety Disorder
GENERALIZED ANXIETY DISORDER
Chronic and excessive worry more days than
not occurring for at least 6 months and
involving many aspects of the person’s life
Persistent exhibition of signs of severe
anxiety: motor tension, apprehensive
expectation, autonomic hyperactivity
Impatience, irritability, unable to concentrate,
fatigue, sleep disturbance
 Diagnostic Criteria for GAD
Motor Tension Autonomic Vigilance or Scanning
Hyperactivity
Trembling Shortness of breath Feeling keyed up or on
Edge
Muscle tension Palpitations or Startling easy
tachycardia
Restlessness Sweating or cold clammy Difficulty concentrating
hands
Easily fatigued Dry mouth Trouble falling asleep or
staying asleep
Dizziness or Irritability
lightheadedness
Nausea, diarrhea, or GI
distress
Hot or cold flashes
Frequent urination
Pharmacotherapy Options for GAD
Drugs of Choice
• SSRIs
• TCAs
• Buspirone
• MAOIs
• Effexor
PHOBIC DISORDERS
Persistent irrational fear attached to an object or
situation that does not pose a significant threat
Anticipatory anxiety – avoidance of situation
Agoraphobia

Simple/Specific Phobias
Social Phobias
 SPESIFIC PHOBIA
• Acrophobia • Fear of heights
• Agoraphobia • Fear of open places
• Ailorophobia • Fear of cats
• Hydrophobia • Fear of water
• Claustrophobia • Fear of closed spaces
• Cynophobia • Fear of dogs
• Myosophobia • Fear of dirt and germs
• Pyrophobia • Fear of fire
• Xenophobia • Fear of strangers
• Zoophobia • Fear of animals
Treatment Options for Specific Phobias
• Behavior therapy
• Insight-oriented psychotherapy
• Hypnosis
• Family therapy
• Exposure therapy
• Pharmacotherapy
• Social Phobia
– Defined as a persistent fear of one or more situations. The
person fears they may act in a way or do something that will
be humiliating or embarrassing in public. Avoidance behavior
interferes with life.

– Examples: Using public bathrooms, speaking in public,

signing name in public, eating in restaurants, or performance
anxiety.
Treatment of Social Phobias
Paxil*
 Beta-blockers:
 Propranolol 10-40mg before performance
 Atenolol 50-100mg for more generalized fears
 Phenelzine up to 90mg/day in divided doses.
 Benzodiazepines: prn or regular dose

*paroxetine hidrochloride
PANIC ATTACKS
 Discrete period of intense apprehension or terror
without any real accompanying danger
accompanied by at least 4 of the following
symptoms:
Palpitations, sweating, trembling, shortness of
breath, feeling of choking, chest pain, abdominal
distress, dizziness, depersonalization, fear of losing
control, fear of dying, paresthesias (numbness), chills
or hot flashes
PANIC DISORDER
 Recurrent unexpected panic attacks that cause
presistent worry about recurrences of
complication from attacks or behavioral change in
response to attack for at least one month
 Sympathomimetic Responses for Panic
Disorder
• Dyspnea •Depersonalization or
• Dizziness/faintness derealization
• Palpitations • Parathesias
• Trembling or shaking • Hot/cold flashes
• Sweating • Chest pain
• Choking • Fear of dying
• Nausea or abdominal distress • Fear of going crazy or doing
something uncontrolled
Treatment for Panic Disorder
 Cognitive behavioral Therapy (effective in
resolving 80% of cases)
 Pharmacotherapy
 Paxil (FDA-approved)
 Zoloft (FDA-approved)
 Imipramine
 Desipramine
 Alprazolam (hi dose)
 Diazepam
 Clonazepam
 Phelzine (may take up to 6 weeks to work)
 Should start antidepressant and prn BZD at the same time Watch for stimulating effects
from antidepressants
 Taper BZD after 1-2 weeks
 Current treatment options should not employ BZDs
OBSESSIVE COMPULSIVE DISORDER (OCD)
• Experience of recurrent obsessions or
compulsions that are time consuming or cause
significant distress or impairment
• Obsessions
– Recurrent intrusive and persistent thoughts, ideas,
images, or impulses
• Compulsions
– Ritualistic behaviors person is compelled to perform
• Reduce anxiety
• Delay to perform ritual results in increasing tension
Nonpsychiatric Clinical Specialists Likely to See Patients
with Obsessive-Compulsive Disorder

• Dermatologist
• Family Practitioner
• Oncologist, infectious disease internist
• Neurosurgeon
• Obstetrician
• Pediatrician
• Pediatric cardiologist
• Dentist
 Symptoms of OCD
Obsessions Compulsions
• Contamination • Checking
• Pathological doubt • Counting
• Somatic • Washing
• Need for symmetry • Need to ask or confess
• Aggressive • Symmetry and precision
• Sexual • Hoarding
• Multiple obsessions • Multiple comparisons
• Other
 Treatment for OCD
• Behavior Therapy
• Psychotherapy
• Pharmacotherapy
– SSRIs
– Prozac
– Luvox
– Paxil
– Zoloft
POST-TRAUMATIC DISTRESS DISORDER
(PTSD)

• Development of characteristic symptoms after

exposure to severe of extraordinary stressor
• Three cardinal features:
– Hyperarousal, recurrent nightmares, and flashbacks
• Sign/Symptom :
– Denial, re-experience of event, perceptual
distortions, feelings of disorganization when thinking
about the event, memory impairment,
overgeneralization of other sensory inputs,
exaggerated startle reaction, somatic symptoms,
altered states of consciousness, recurrent nightmares
• Acute PTSD may last up to three months
• Chronic PTSD persists longer than three
months
• PTSD is often accompanied by other
psychiatric disorders including, depression,
substance abuse, and personality disorders
 Additional Symptoms of PTSD
• Alienating yourself to prevent stressful situations
• Avoiding people and places that remind you of the trauma
• Panicking in social situations you cannot escape
• Hiding your feelings of anxiety and fear
• Smiling or laughing so others think you’re happy
• Withdrawing from relationships with loved ones
• Struggling to fall asleep … and stay asleep
• Reliving the trauma in dreams and flashbacks
• Suffering in your performance at work
• Drinking or abusing drugs to mask your problems
• Avoiding plans for a future you doubt you’ll see
• Thinking about suicide
• Feeling like you’re facing all of this alone
 Treatment of PTSD
Patients receiving adequate treatment have an
median recovery time of 36 months, as compared
with 64 months in patients who are untreated.
 Psychotherapy
 Behavioral Therapy
 Pharmacotherapy

The primary goal of chronic PTSD with co-morbid

psychiatric conditions is treatment of symptoms in
conjunction with psychotherapy.
• Cognitive therapy
• Exposure therapy
• EMDR (Eye Movement Desensitization and
Reprocessing )
• Pharmacotherapy
ronny3w@yahoo.com