1.

2.
3.
4.
5.
6.
7.

Teori gangguan cemas dan gangguan panik tanpa

agorafobia
Psikopatologi dan definisi gangguan cemas-panik
Hirarki diagnosis gangguan cemas-panik menurut
PPDGJ III
Diagnosis menurut Aksis
Pemeriksaan fisik, penunjang (EKG, ECG), dan
laboratorium (Fungsi Tiroid)
Penatalaksanaan & indikasi rawat inap
Prognosis gangguan cemas-panik

Pendahuluan
Gangguan Neurotik / Psikoneurosis :
oleh DSM-IV diklasifikasikan dalam
kelompok :
- Gangguan cemas
- Gangguan somatoform
- Gangguan disosiatif
- (Gangguan Factitious)
oleh PPDGJ-III diklasifikasikan sebagai
F 4 - Gangguan Neurotik
- Gangguan Somatoform
- Gangguan terkait stress

Pendahuluan
Gangguan Panik
serangan panik yang spontan dan tidak
diperkirakan
Serangan Panik
periode kecemasan / ketakutan yg kuat
dan relatif singkat, disertai gejala somatik
tertentu (palpitasi dan takipnea)
DSM IV
- Gangguan Panik dengan Agorafobia
- Gangguan Panik tanpa Agorafobia

Gangguan Cemas
Sensasi kecemasan sering dialami oleh
hampir semua manusia
Perasaan tsb ditandai dg :
- rasa ketakutan yg difus, tdk
menyenangkan dan samar-samar
- sering disertai gejala otonomik :
nyeri kepala, berkeringat, palpitasi,
nyeri dada dan gg lambung ringan
Dibagi 2 :
- kecemasan normal / fisiologis
- kecemasan patologis

Kecemasan normal / fisiologis

- kecemasan : suatu sinyal yg
menyadarkan, memperingatkan adanya
bahaya yang mengancam dan
memungkinkan seseorang mengambil
tindakan utk mengatasi ancaman
- pengalaman kecemasan ada 2 komponen
:
kesadaran adanya sensasi fisiologis
(seperti berdebar-debar dan
berkeringat)
kesadaran sedang ketakutan
Kecemasan Patologis
teori penyebab kecemasan

1. Teori Psikologis :
- teori psikoanalitik
- teori perilaku
- teori eksistensial
2. Teori Biologis

Teori Psikoanalitik
kecemasan masuk dlm 4 kategori utama
tergantung pd sifak akibat yg ditakutinya :
- kecemasan impuls
- kecemasan perpisahan
- kecemasan kastrasi
- kecemasan super ego
Teori Perilaku
kecemasan adlh suatu respon yg dibiasakan
thd stimuli lingkungan spesifik
Teori Eksistensial
seseorg menjadi menyadari adanya
kehampaan yg menonjol di dlm dirinya, perasaan
yg mgkn lebih mengganggu daripada penerimaan
kematian mereka yg tdk dapat dihindari

Teori Biologis
adanya peristiwa biologis yg mendahului
konflik psikologis
Stimulasi saraf otonom menyebabkan gejala2
tertentu :
- Kardiovaskuler : takikardia
- Muskuler : nyeri kepala
- Gastrointesitinal : diare
- Pernapasan : nafas cepat
ada 3 neurotransmitter yg berhub dg
kecemasan :
- Norepinefrin
- Serotonin
- GABA

Epidemiologi
Umumnya dijumpai pada anak-anak dan orang
dewasa sebelum usia 35 tahun
Hampir 5 % dari penduduk pernah menderita
kecemasan akut maupun kronik
: =2:1
Manifestasi gg cemas pada anak dpt berupa :
- problem pada waktu pemberian makan / susah
utk makan
- sulit utk BAB
- menghisap ibu jari
- rewel
- mengompol

Psikopatologi

Clinical Features of
Anxiety
Psychologic
fear and
apprehension
inner tension and
restlessness
irritability
impaired ability to
concentrate
increased startle
response
increased sensitivity
to physical sensations
disturbed sleep

Physical
increased muscle tension
tremor
sweating
palpitations
chest tightness and
discomfort
shortness of breath
dry mouth
difficulty swallowing
diarrhea
frequency of micturition
loss of sexual interest
dizziness
numbness and tingling
faintness

Diagnostik Gg Cemas-Panik Multi

Aksial

TUJUAN : Mencakup informasi yang komperhensif (gangguan jiwa, kondisi

medik umum, masalah psikososial dan lingkungan, taraf fungsi secara global),
sehingga dapat membantu dalam perencanaan terapi dan memperkirakann
outcome atau prognosis.

Aksis I
Gangguan klinis
Kondisi lain yg menjadi fokus perhatian khusus
Aksis II
Gangguan kepribadian
Retardasi mental
Aksis III
Kondisi medik umum
Aksis IV
Masalah psikososial dan lingkungan
Aksis V
Penilaian fungsi secara global
Antara aksis I, II, III tidak selalu ada hub etiologik n patogenesis
Hub antara aksis I, II, III dan aksis IV dapat tmbal balik saling mempengaruhi

Diagnostik Cemas

F 40 F 48
Gangguan Neurotik, Gangguan Somatoform
dan Gangguan yang Berkaitan dengan Stress
F 40 : Gangguan anxietas fobik
F 40.0 Agorafobia
.00 Tanpa gangguan panik
.01 Dengan gangguan panik
F 40.1 Fobia sosial
F 40.2 Fobia khas (terisolasi)
F 40.8 Gangguan anxietas fobik lainnya
F 40.9 Gangguan anxietas fobik YTT
F 41 : Gangguan anxietas lainnya
F 41.0 Gangguan panik (anxietas paroksimal episodik)
F 41.1 Gangguan anxietas menyeluruh
F 41.2 Gangguan campuran anxietas dan depresif
F 41.3 Gangguan anxietas campuran lainnya
F 41.8 Gangguan anxietas lainnya YDT
F 41.9 Gangguan anxietas YTT
F 45 : Gangguan somatoform
F 45.0 Gangguan somatisasi
F 45.1 Gangguan somatoform tak terinci
F 45.2 Gangguan hipokondrik
F 45.3 Disfungsi otonomik somatoform

F4. Gangguan Neurotik, gangguan

somatoform, dan gangguan terkait
stres
F40. Gg anxietas fobik
dicetuskan oleh adanya situasi atau
objek yang sebenarnya tidak
membahayakan, dihindari dan bila
dihadapi dengan kecemasan hebat
- F40.0. Agorafobia : takut tempat
terbuka
- F40.1. Fobia sosial : situasi sosial
tertentu
- F40.2. Fobia khas

 F41.0. Gangguan panik :

- Serangan anxietas berat berulang dalam satu bulan
- Timbul tiba-tiba
- Berlangsung sebentar (5-15 menit)
F41.1. Gangguan cemas menyeluruh :
- Gejala anxietas primer yang berlangsung hampir setiap
hari dalam waktu beberapa minggu-bulan
- Mengenai kehidupan sehari-hari,
- Bersifat free floating
- Gejala berupa : kecemasan, ketegangan motorik,
overaktivitas otonom
F41.2. Gangguan campuran anx-dep :
anxietas dan depresi tidak berat

 F42. Gangguan obsesif-kompulsif :

- Gejala obsesif atau kompulsif ditemukan
hampir setiap hari selama 2 minggu berturutturut
Gejala obsesif :
- pikiran disadari berasal dari dirI sendiri,
- terkadang tidak berhasil dilawan, bila
dilakukan hanya menimbulkan perasaan lega
- Pikiran tersebut berulang-ulang dan tidak
menyenangkan

F43. Reaksi terhadap stres berat dan gg

penyesuaian
F43.0. Reaksi stres akut :

- Reaksi terhadap trauma/stresor bersifat

katastropik, biasanya setelah beberapa
menit atau segera, menghilang dalam
beberapa hari (3 hari)
- Gejala yang timbul : terpaku (daze),
dapat disertai gejala cemas,depresi,
marah, menarik diri dll

 F43.1. Gangg stres pasca trauma

- Dalam kurun waktu 6 bulan setelah
kejadian traumatik
- Gejala flashback, re-experience,
avoidance
F43.2. Gangguan penyesuaian
- Reaksi terhadap stres dalam kehidupan
sehari-hari. Hal ini tergantung dari berat
ringan stres, kepribadian seseorang

F45. Gangguan somatoform

Keluhan gejala-gejala fisik yang berulang-ulang, disertai dengan
permintaan pemeriksaan medik tidak ditemukan kelainan
Menyangkal adanya konflik
Tidak mau mendengarkan penjelasan dokter
- F45.0. Gg Somatisasi
banyak keluhan fisik 2 tahun
- F45.1. Gg somatoform tak terinci
keluhan > tapi tidak penuhi somatisasi
- F45.2. Gg hipokondrik
keyakinan menetap adanya penyakit fisik yang serius
- F45.3. Disfungsi otonomik
keluhan otonomik berulang
- F45.4. Nyeri somatoform menetap
gejala nyeri dominan dan menetap

ANXIETY DISORDERS
INCLUDE

PANIC ATTACK
AGORAPHOBIA
PANIC DISORDER W./OUT AGORAPHOBIA
AGORAPHOBIA W./OUT HISTORY OF PANIC DISORDER
SPECIFIC PHOBIA
SOCIAL PHOBIA
OBSESSIVE-COMPULSIVE DISORDER
POST-TRAUMATIC STRESS DISORDER
ACUTE STRESS DISORDER
GENERALIZED ANXIETY DISORDER
ANXIETY DISORDERS DUE TO GENERAL MEDICAL
CONDITION
SUBSTANCE-INDUCED ANXIETY DISORDER
ANXIETY DISORDER NOT OTHERWISE SPECIFIED (NOS)

PANIC ATTACK
A DISCRETE PERIOD IN WHICH THERE IS A
SUDDEN ONSET OF INTENSE
APPREHENSION, FEARFULNESS, OR
TERROR, OFTEN ASSOCIATED WITH
FEELINGS OF IMPENDING DOOM. OFTEN
ACCOMPANIED BY SYMPTOMS OF
SHORTNESS OF BREATH, PALPITATION,
CHEST PAIN OR DISCOMFORT, CHOKING OR
SMOTHERING SENSATIONS, AND FEAR OF
GOING CRAZY OR LOSING CONTROL.

EXAMPLES OF PANIC ATTACKS

WHEN CAUGHT UP IN TRAFFIC JAMS
THOUGHT OF IMPENDING DANGER OR
DEATH, OR ILL-OMEN AND SO AVOID
CONTINUING A TASK WITH WHICH HE IS
ENGAGED
HEART PALPITATION INTERPRETED AS A
FATAL HEART ATTACK AND SO REPEATED
VISITS TO EMERGENCY UNIT
FEAR OF TRAVELLING ALONE, SHOULD
HAVE COMPANY

AGORAPHOBIA
(Agora=market place, phobia=fear)

ANXIETY ABOUT, OR AVOIDANCE OF,

PLACES OR SITUATION FROM WHICH
ESCAPE MIGHT BE DIFFICULT (OR
EMBARRASSING) OR IN WHICH HELP
MAY NOT BE AVAILABLE IN THE EVENT
OF HAVING A PANIC ATTACK OR PANICLIKE SYMPTOMS

EXAMPLES OF AGORAPHOBIA
MILD:
APPREHENSION HAVING SOCIAL GATHERING WITH ca. 20
PEOPLE OR MORE, WITH COMPLAINTS OF NAUSEA,
VOMITING, STOMACH ACHES, DIARRHOEA

MODERATE:
DARE NOT TO WALK ALONE ON THE STREET
AVOID GOING INTO SHOPPING MALLS OR DEPARTMENT
STORES, ESPECIALLY MARKET PLACE
FEAR OF WALKING ALONE IN THE CORRIDOR OF BIG
BUILDING

SEVERE:
HOUSE-BOUND HOUSE-WIVES, DARE NOT TO LEAVE
HOME

PANIC DISORDER W./OUT

AGORAPHOBIA
RECURRENT UNEXPECTED PANIC ATTACKS
ABOUT WHICH THERE IS PERSISTENT
CONCERN
PANIC DISORDER W./ AGORAPHOBIA IS
CHARACTERIZED BY BOTH RECURRENT
UNEXPECTED PANIC ATTACKS AND
AGORAPHOBIA
AGORAPHOBIA W./OUT HISTORY OF PANIC
DISORDER, CHARACTERIZED BY PRESENCE
OF AGORAPHOBIA AND PANIC-LIKE
SYMPTOM W./OUT A HISTORY OF
UNEXPECTED PANIC ATTACKS

SPECIFIC PHOBIA
(SIMPLE PHOBIA)
CHARACTERIZED BY CLINICALLY
SIGNIFICANT ANXIETY PROVOKED BY
EXPOSURE TO A SPECIFIC FEARED OBJECT
OR SITUATION OFTEN LEADING TO
AVOIDANCE BEHAVIOUR.
ANIMAL TYPE (fear of dogs, cats, lizards,
cockroaches)
NATURAL ENVIRONMENT TYPE (fear of space,
prairie)
BLOOD-INJECTION TYPE (fear of blood, medical)
SITUATIONAL TYPE, (tunnel, flying, enclosed places)

SOCIAL PHOBIA
CHARACTERIZED BY CLINICALLY
SIGNIFICANT ANXIETY PROVOKED BY
EXPOSURE TO CERTAIN TYPES OF SOCIAL
OR PERFORMANCE SITUATIONS, OFTEN
LEADING TO AVOIDANCE BEHAVIOUR
SUCH AS EATING OUT ALONE IN RESTAURANT
LECTURER FEARS OF LECTURING OR
PRESENTING IN FRONT OF STUDENTS OR AN
AUDIENCE
FEAR OF BLUSHING AND NOTED BY OTHERS
FEAR OF MEETING WITH SUPERIORS OR HIGH
RANKING PERSONS
UNEASY ENCOUNTERING PEOPLE

OBSESSIVE-COMPULSIVE
DISORDER
CHARACTERIZED BY OBSESSIONS (WHICH
CAUSE MARKED ANXIETY OR DISTRESS)
&/OR BY COMPULSION (WHICH SERVE TO
NEUTRALIZE ANXIETY)
INCESSANT COMING OF NUMBERS OR IDEAS,
WHEN DRIVING A CAR, DOUBTFUL WHETHER HE
HAD HIT A PERSON
FREQUENT HAND-WASHING W./OUT REASONS
SUCH AS FEAR OF DIRT / BACTERIA.
WOMAN WHO FEARS SPLASH OF WASTE WATER
FREQUENT CHECKING OF LOCKED DOORS.

POST-TRAUMATIC STRESS
DISORDER
CHARACTERIZED BY THE REEXPERIENCING OF AN EXTREMELY
TRAUMATIC EVENT ACCOMPANIED BY
SYMPTOMS OF INCREASED AROUSAL
AND BY AVOIDANCE OF STIMULI
ASSOCIATED WITH THE TRAUMA
SUCH AS BUS, TRAIN / PLANE CRASH
WITH MANY DEATH TOLLS
RIOTING, BEING MOLESTED OR RAPED

ACUTE STRESS DIORDER

CHARACTERIZED BY SYMPTOMS
SIMILAR TO THOSE OF POSTTRAUMATIC STRESS DISORDER THAT
OCCUR IMMEDIATELY IN THE
AFTERMATH OF AN EXTREMELY
TRAUMATIC EVENT
BIG FIRE
TERRORISTS GUNS & BOMBS
FIRE-ARMED ROBBERIES

GENERALIZED ANXIETY DISORDER

CHARACTERIZED BY AT LEAST 6 MONTHS OF
PERSISTENT AND EXCESSIVE ANXIETY AND
WORRY
Excessive anxiety & worry (apprehensive expectation).
Occurring more days than not for at least 6 months about
events like work or school performance
Difficult to control the worry
Restless, feeling keyed up or on edgy
Irritability
Difficulty concentrating
Disturbed sleep
Impairment in social, occupational or other functioning

ANXIETY DISORDER DUE TO A

GENERAL MEDICAL CONDITION
CHARACTERIZED BY PROMINENT
SYMPTOMS OF ANXIETY THAT ARE JUDGED
TO BE A DIRECT PHYSIOLOGICAL
CONSEQUENCE OF A GFENERAL MEDICAL
CONDITION
Prominent anxiety, panic, or obsessions &
compulsions
Physical & lab findings is the direct physiological
consequence of gen. med. Conditions
Caused distress & impairment in social &
occupational & other areas of functioning

SUBSTANCE-INDUCED
ANXIETY DISORDER
CHARACTERIZED BY PROMINENT
SYMPTOMS OF ANXIETY THAT ARE JUDGED
TO BE A DIRECT PHYSIOLOGICAL
CONSEQUENCES OF A DRUG OF ABUSE,
MEDICATION, OR TOXIN EXPOSURE
Prominent anxiety, panic, obsession & compulsions
Developed during or within 1 month of substance
intoxication or withdrawal
Medication use is etiologically related to the
disturbance

ANXIETY DISORDER
NOT OTHERWISE SPECIFIED (NOS)
FOR CODING DISORDERS WITH PROMINENT
ANXIETY OR PHOBIC AVOIDANCE THAT DO
NOT MEET CRITERIA FOR ANY OF THE
SPECIFIC ANXIETY DISORDERS DEFINED IN
THIS SECTION (OR ANXIETY SYMPTOMS
ABOUT WHICH THERE IS INADEQUATE OR
CONTRADICTORY INFORMATION)
SEPARATION ANXIETY DISORDER (CHILD)
PHOBIC AVOIDANCE TO GENITAL SEXUAL
CONTACT

CRITERIA FOR PANIC ATTACK

A DISCRETE PERIOD OF INTENSE FEAR OR
DISCOMFORT, IN WHICH 4 (OR >) OF THE
FOLLOWING SYMPTOMS DEVELOPED
ABRUPTLY, AND REACHED A PEAK WITHIN 10
MINUTES:

PALPITATIONS
SWEATING
TREMBLING OR SHAKING
SENSATION OF SHORTNESS OF BREATH /
SMOTHERING
FEELING OF CHOKING

 CHEST PAIN OR DISCOMFORT

NAUSEA OR ABDOMINAL DISTRESS
FEELING DIZZY, UNSTEADY, LIGHTHEADED, OR
FAINT
DEREALIZATION (FEELING OF UNREALITY) OR
DEPERSONALIZATION (DETACHED FROM ONESELF)
FEAR OF LOSING CONTROL OR GOING CRAZY
FEAR OF DYING
PARESTHESIAS (NUMBNESS OR TINGLING
SENSATIONS)
CHILLS OR HOT FLASHES

SOMATOFORM DISORDERS
PRESENCE OF PHYSICAL SYMPTOMS THAT
SUGGEST A GENERAL MEDICAL CONDITION
NOT FULLY EXPLAINED BY THAT GEN. MED.
CONDITION, NOR THE DIRECT EFFECTS OF
A SUBSTANCE OR MENTAL DISORDER (PANIC)
SOMATIZATION DISORDER (HYSTERIA /
BRIQUETS SYNDROME)
CONVERSION DISORDER
PAIN DISORDER
HYPOCHONDRIASIS
BODY DYSMORPHIC DISORDER

SOMATIZATION DISORDER
HISTORY OF MANY PHYSICAL COMPLAINTS
BEFORE AGE 30 YRS OCCUR FOR SEVERAL
YRS RESULT IN TREATMENT BEING SOUGHT
OR SIGNIFICANT IMPAIRMENT IN SOCIAL,
OCCUPATIONAL OR OTHER AREAS OF
FUNCTIONING
4 PAIN SYMPTOMS e.g. head, abdomen, back, joints,
extremities, chest, rectum, during menstruation, sexual
intercourse, or urination
2 gastrointestinal symptoms, e.g. nausea, bloating,
vomiting (not during pregnancy), diarrhoea,
intolerance of several foods

 1 sexual symptom e.g. sexual indifference, erectile or

ejaculatory dysfunction, irregular menses, excessive
menstrual bleeding, vomiting throughout pregnancy
1 pseudo-neurological symptom e.g. conversion symptom
like impaired coordination or balance, paralysis or
localized weakness, difficult swallowing or lump in throat,
aphonia, urinary retention, hallucinations, loss of touch or
pain sensation, double vision, blindness, deafness,
seizures, dissociative symptoms such as amnesia, or
loss of consciousness
Those symptoms (B) cannot be fully explained
If there is related gen. med. Cond. Physical complaints &
resulting social & occupational impairment are in excess of
what would be expected.
The symptoms are not intentionally produced or feigned

CONVERSION DISORDER
1 / > Symptoms or deficits affectidistressng voluntary
motor or sensory function that suggest a neurological or
other gen. med. Condition.
Psychological factors are judged to be associated with the
symptom or deficit because the initiation or exacerbation
of the symptom or deficit is preceded by conflicts or other
stressors.
The symptom or deficit is not intentionally produced or
feigned.
The symptom or deficit cannot be fully explained by a gen.
med. Condition, substance effect or as a culturally
sanctioned behaviour or experience
The symptom & deficit causes distress or impairment in
social, occupational or other important areas of functioning

PAIN DISORDER
PAIN IN ONE OR MORE ANATOMICAL SITES IS THE
PREDOMINANT FOCUS OF THE CLINICAL PRESENTATION &
IS OF SUFFICIENT SEVERITY TO WARRANT CLINICAL
ATTENTION
THE PAIN CAUSES DISTRESS OR IMPAIRMENT IN SOCIAL,
OCCUPATIONAL OR OTHER IMPORTANT AREAS OF
FUNCTIONING
PSYCHOLOGICAL FACTORS ARE JUDGED TO HAVE AN
IMPORTANT ROLE IN THE ONSET, SEVERITY,
EXACERBATION, OR MAINTENANCE OF THE PAIN
THE SYMPTOM OR DEFICIT IS NOT INTENTIONALLY
PRODUCED OR FEIGNED (AS IN FACTITIOUS DISORDER OR
MALINGERING)
THE PAIN IS NOT BETTER ACCOUNTED FOR BY A MOOD,
ANXIETY, OR PSYCHOTIC DISORDER AND DOES NOT MEET
CRITERIA FOR DYSPAREUNIA

HYPOCHONDRIASIS

PREOCCUPATION WITH FEARS OF HAVING, OR THE IDEA THAT

ONE HAS, A SERIOUS DISEASE BASED ON THE PERSONS
MISINTERPRETATION OF BODILY SYMPTOMS
THE PREOCCUPATION PERSISTS DESPITE APPROPRIATE
MEDICAL EVALUATION AND ASSURANCE
THE BELIEF IN THE ABOVE IS NOT OF DELUSIONALINTENSITY
(AS IN DELUSIONAL DISORDER, SOMATIC TYPE) AND IS NOT
RESTRICTED TO A CIRCUMSCRIBED CONCERN ABOUT
APPEARANCE (AS IN BODY DYSMORPHIC DISORDER)
THE PREOCCUPATION CAUSES CLINICALLY SIGNIFICANT
DISTRESS OR IMPAIRMENT IN SOCIAL, OCCUPATIONAL &
OTHER IMPORTANGT AREAS OF FUNCTIONING
THE DURATION OF THE DISTURBANCE IS AT LEAST 6 MONTHS
THE PREOCCUPATION IS NOT BETTER ACCOUNTED FOR BY
GENERALIZED ANXIETY DISORDER, OCD, PANIC DISORDER,
MAJOR DEPRESSIVE EPISODE, SEPARATION ANXIETY, OR
ANOTHER SOMATOFORM DISORDER

BODY DYSMORPHIC DISORDER

PREOCCUPATION WITH AN IMAGINED DEFECT IN
APPEARANCE. IF A SLIGHT PHYSICAL ANOMALY IS
PRESENT, THE PERSONS CONCERN IS MARKEDLY
EXCESSIVE
THE PREOCCUPATION CAUSES CLINICALLY
SIGNIFICANT DISTRESS OR IMPAIRMENT IN
SOCIAL, OCCUPATIONAL, OR OTHER IMPORTANT
AREAS OF FUNCTIONING.
THE PREOCCUPATION IS NOT BETTER
ACCOUNTED FOR BY ANOTHER MENTAL DISORDER
(e.g. dissatisfaction with body shape and size in
Anorexia Nervosa