14.26 Gangguan Cemas

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GANGGUAN CEMAS ANXIETY DISORDER By Dr. IBRAHIM PUTEH, SpKJ

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Transcript of 14.26 Gangguan Cemas

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GANGGUAN CEMASANXIETY DISORDER

By Dr. IBRAHIM PUTEH, SpKJ

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N ? - Anamnese

ANSIETAS - PemeriksaanPatologis ?

Cemas menetapGangguan fungsi e/c distressGejala 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

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Stress ( ST ) - MPENormal - Coping mekanisme

SakitS kalau ST > MPE & CM

Eksternal Pressure dunia luarimbalance Vs

Ego personSAKIT

Internal Impuls ( Dependence, Agressive,imbalance Sexual )

Vs Conscience ( Nurani )

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GANGGUAN ANSIETAS

1. Panic Disorder - Agora Phobia (+)- Agora Phobia ( - )

2. Specific & Socio Phobia3. OCD4. Post Traumatic Stress Disorder5. Acute Stress Disorder6. GAD7. AD due to General Medical Condition8. AD NOS9. Mixed Anxiety Depressive Disorder10. Subtance Induced AD

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Disorders Associated with Anxiety

Neurological disorders Endocrine disturbancesCerebral neoplasma Pituitary dysfunctionCerebral trauma and Thyroid dysfunction post concussive syndromes Parathyroid dysfunctionCerebrovascular disease Adrenal dysfunctionSubarachnoid hemorrage PheocromocytomaMigraine Vilirization disorders of femalesEncephalitisCerebral syphilis Inflammatory disordersMultiple sclerosis Lupus erythematosusWilson’s disease Rheumatoid arthritisHuntington’s disease Polyarteritis nodosaEpilepsy Temporal arteritis

Systemic conditions Deficiency statesHypoxia Vit B12 deficiency Cardiovascular disease Pellagra Cardiac arrhythmias Pulmonary insufficiency Anemia

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Miscellaneous conditions Toxic conditions

Hypoglycemia Alcohol and drug withdrawalCarcinoid syndrome AmphetaminesSystemic malignancies Sympathomimetic agentsPremenstrual syndrome Vasopressor agentsFebrile illness and chronic infections Caffeine and caffeine withdrawalPorphyria PenicillinInfectious mononucleosis SulfonamidesPosthepatitis syndrome CannabisUremia Mercury

ArsenicIdiopathic psychiatrist disorders Phosphorus

Depression OrganophosphatesMania Carbon disulfideSchizophrenia BenzeneAnxiety disorders Aspirin intoleranceGeneralized anxietyPanic attacksPhobic disordersPost traumatic stress disorders

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Psychoanalytic Neuroses and Disorders in DSM-IV

Classic Neuroses DSM-IV Classification

Anxiety Generalized anxiety disorder

Phobic Agoraphobia, specific and socialphobia

Obsessive-compulsive Obsessive-compulsive disorder

Depressive Dysthymic disorder

Hysterical (conversion) Conversion disorder

Hysterical (dissociative) Depersonalization disorder

Hypochondriacal Hypochondriasis

Paraphilic Sexual disorder

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Peripheral Manifestations of Anxiety

DiarrheaDizziness, light-headednessHyperhidrosisHyperreflexiaHypertensionPalpitationPupillary mydriasisRestlessness ( e.g pacing )SyncopeTachycardiaTingling in the extremitiesTremorsUpset stomach (“butterflies”)Urinary frequency, hesitancy, urgency

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PANIC DISORDER AND AGORA PHOBIA

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

N T : Norephinephrin, GABA, SerotoninPanicogen : CO2, Laktat

Gambaran klinis

Psikis : Sulit bicara, memory terganggu, depresi Depersonalisasi saat serangan

Associated symptom --- depresi

Agoraphobia Sering dengan - PHK- Marital discord- NAPZA abuse

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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

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Criteria for AgoraphobiaNote : 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 ofhaving an unexpected or situationally predisposed panic attack or paniclike symptom. Agoraphobia fears typically involve characteristic cluster ofsituations that include being in outside the home alone; being in a crowd orstanding in a line; being on the bridge; and traveling in a bus, train or automobile.Note : Consider the diagnosis of specific phobia if the avoidance is limited toone 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 withmarked distress or with anxiety about having a panic attack or panic-likesymptom, or require the presence of a companion.

C. The anxiety or public avoidance is not better accounted for by anothermental disorders, such as social phobia (e.g. avoidance limited to socialsituations because of fear of embarrassment), specific phobia (e.g. avoidance limited to a single situation like elevators), obsessivecompulsive disorder (e.g. avoidance of dirt in someone with obsession aboutcontamination), post traumatic stress disorder (e.g. avoidance of stimuli associatedwith a severe stressor), or separation anxiety disorder (e.g. avoidance of leaving home or relatives).

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Diagnostic Criteria for Panic AttackNote : A panic attack is not a codable disorder. Code the specific diagnosis inwhich the panic attack occurs (e.g. panic disorder with agoraphobia)A discrete period of intense fear or discomfort, in which four (or more) of thefollowing symptom developed abruptly and reached a peak within 10 minutes.1. Palpitations, pounding heart, or accelerated heart rate2. Sweating3. Trembling or shaking4. Sensation of shortness of breath or smoothering5. Feeling of choking6. Chest pain or discomfort7. Nausea or abdominal distress8. Feeling dizzy, unsteady, lightheaded, or faint9. Derealization (feeling of unreality) or depersonalization (being detached from

oneself)10. Fear of loosing control or going crazy11. Fear of dying12. Paresthesias (numbness or tingling sensations)13. Chills or hot flushes

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SPECIFIC PHOBIA AND SOCIAL PHOBIA

Incidence : Wanita 2 x > PriaSpecific Phobia >> Social PhobiaSocial Phobia 3/100 orang ( usia 5 – 35 thn )

Specific Phobia Objek khusus c/ - Binatang - Ketinggian - Kematian dll

Treatment : Insight Oriented PsychotherapyHypnosis Bangkitkan fobia objek

Social phobia Pharmacotherapy - Anti Ansietas - Anti Depressan

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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 ordistress.

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E. The avoidance, anxious anticipation, or distress in the feared situation(s)interferes significantly with the person’s normal routine, occupational (or academic) functioning, or social activities or relationship with others, orthere 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 specificobject 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 typeNatural environment type (e.g. heights, storms, and water)Blood, injection, injury typeSituational 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)

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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 possiblescrutiny 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 peersetting, 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 predisposedpanic 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 enduredwith intense anxiety or distress.

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E. The avoidance, anxious anticipation, or distress in the feared social orperformance situation(s) interferes significantly with the person normalroutine, 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 schizoidpersonality disorder)

H. If a general medical condition or other mental disorder is present, the fear incriterion 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.

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OBSESSIVE COMPULSIVE DISORDER( OCD )

OBSESSI : Keadaan dimana pikiran bertahan pada satu hal ( berulang-ulang )

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

Obsessi Ansietas meningkatKompulsi Ego Dystonik

Live time prevalence 2 – 3 %

Therapy ( lihat diagram )

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Diagnostic Criteria for Obsessive-Compulsive DisorderA. 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 area product of his or her own mind (not imposed from without as in thoughtinsertion)

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 toperform in response to an obsession, or according to the rules that must beapplied rigidly

(2) The behavior of mental acts are aimed at preventing or reducing distress orpreventing 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

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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 person’snormal 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 tricothilomaniaconcern with appearance of the body dysmorphic disorder : preoccupationwith drugs in the presence of a substance use disorder : preoccupation with having serious illness in the presence of hypochondriasis : preoccupationwith 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

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No changeIf panicPresent Partial change

Partial orNo change

If anxious if depressed if tics, delusional ?

If suicidal

Failed Plus 2SRis suicidal 3 combinations incapacitated ECT Behavior treatment

SRI

MAOISwitch

SRI

Combinationtreatment

Buspirone Lithium Neuroleptic Fenfluramine

Still ill?

ECTNovel

Treatmentse.g, anti-androgen

Psychosurgery

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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

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ASD Keluhan symptom muncul setelah 4 mingguPeristiwa traumatic dan hilang dalam 2 hari s/d 4 minggu

Incidence 1 – 3 %

Predisposisi1. Childhood trauma2. Kepribadian borderline, paranoid, dependent, and antisocial trait3. Inadequate support system4. Rapuh terhadap gangguan mental5. Kehidupan penuh stress6. Alkoholic

Prognosa baik bila Therapy1. Sakit singkat Pharmacotherapy2. Fungsi premorbid baik - Sedative, Hypnotic, Antidepressant3. Strong social support Psychotherapy4. Rapid onset of the symptom - Behavior, Cognitive, Hypnosis5. Tidak ada gangguan psikiatrik,

drug abuse dan sakit medis

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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 k/p- Anti depressan k/p

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Diagnostic Criteria for Anxiety Disorder Due to a General Medical Condition

A. Prominent anxiety, panic attack, obsessions or compulsions predominate the clinical picture

B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition

C. 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)

D. The disturbance does not occur exclusively during the course of deliriumE. The disturbance causes clinically significant distress or impairment in social,

occupational, or other important areas of functioning

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

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SUBSTANCE INDUCED ANXIETY DISORDER

ETIOLOGISubstance Simphatomimetic

- Amphetamin - Cocaine - Caffeine

Serotonergic - LSD / MDMA

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

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TERIMA KASIH