GANGGUAN CEMAS

(ANXIETY DISORDER)

By Dr. IBRAHIM PUTEH, SpKJ

 N? - Anamnese
CEMAS - 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, vague
sense of apprehension
Beda dgn rasa takut
- Cemas : Ancaman unknown, Internal, Vague, diffus. Berasal dari konflik.

- Takut : Reality threatened, External. Non konflik.

- GABA
NT - Serotonin
- Norephineprin
 Stress ( ST ) - MPE
Normal - Coping mekanisme

Sakit kalau Sress > MPE & CM

Eksternal  Pressure dunia luar

imbalance Vs
Ego person
SAKIT

Internal  Impuls ( Dependence, Agressive,

imbalance Sexual )
Vs
Conscience ( Nurani )
Perbedaan Cemas dengan Takut.
= Cemas
- Sebagai respon dari ancaman yang tidak
diketahui, internal, ok konflik dan sifatnya
samar.

= Takut
- Sebagai respon dari ancaman yang nyata,
eksternal, non konflik.
 GANGGUAN CEMAS.

1. Panic Disorder - Agora Phobia (+)

- Agora Phobia ( - )
2. Specific & Socio Phobia
3. OCD
4. Post Traumatic Stress Disorder
5. Acute Stress Disorder
6. GAD
7. AD due to General Medical Condition
8. AD NOS
9. Mixed Anxiety Depressive Disorder
10. Subtance Induced AD
Gangguan yang berhubungan dengan Cemas.
Neurological disorders
Cerebral neoplasma
Cerebral trauma and
post concussive syndromes
Cerebrovascular disease
Subarachnoid hemorrage
Migraine
Encephalitis
Cerebral syphilis
Multiple sclerosis
Wilson’s disease
Huntington’s disease
Epilepsy
Systemic conditions
Hypoxia
Cardiovascular disease
Cardiac arrhythmias
Pulmonary insufficiency
Anemia
Endocrine disturbances
Pituitary dysfunction
Thyroid dysfunction
Parathyroid dysfunction
Adrenal dysfunction
Pheocromocytoma
Vilirization disorders of females
Inflammatory disorders
Lupus erythematosus
Rheumatoid arthritis
Polyarteritis nodosa
Temporal arteritis
Deficiency states
Vit B12 deficiency
Pellagra
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
Peripheral Manifestasi perifer dari Cemas;

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 : Norephinephrin, GABA, Serotonin

Panicogen : 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 person’s 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.
F. 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  Ansietas meningkat

Kompulsi  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 person’s
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
trichotilomania 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
If panic
Present Switch Partial change
MAOI SRI
Partial or
No change

Combination
treatment
If anxious if depressed if tics, delusional ?

Buspirone Lithium Neuroleptic Fenfluramine

Still ill?
If suicidal
Novel
ECT Treatments
e.g, anti-
Failed Plus
2SRis suicidal androgen
3 combinations incapacitated
ECT
Behavior treatment

Psychosurgery
 POST TRAUMATIC STRESS DISORDER ( PTSD )
POST TRAUMATIC STRESS STRESS DISORDER ( PTSD )

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
PTSD  Keluhan symptom muncul setelah 4 minggu
Peristiwa traumatic.
Incidence 1–3%

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:
1. Sakit singkat
2. Fungsi premorbid baik
3. Strong social support
4. Rapid onset of the symptom.
5. Tidak ada gangguan psikiatrik, drug abuse dan
sakit medis
Therapy :
1. Farmakoterapi.
- Sedative, Hypnotic, Antidepressant.

2. Psikoterapi.
- Behavior terapi.
- Cognitive terapi.

2. Hypnosis.
Kriteria Diagnostik Gangguan Stres Pasca Trauma
(PTSD) :
A. Penderita terekspos dgn peristiwa traumatik
melalui keadaan berikut;
1. Penderita mengalami, menyaksikan atau ter- konfrontir
dgn kejadian nyata ancaman kematian atau luka serius
atau ancaman integritas fisik dirinya atau orang lain.
2. Penderita terlibat dalam respon ketakutan yang sangat,
tidak ada harapan atau menyeramkan.
B. Mengalami atau telah mengalami peristiwa yang
penuh stres, penderita mempunyai 3 atau lebih
gejala disosiativ dibawah ini:
1. menumpulnya perasaan subjektif atau tidak ada
 Lanjutan.....
2. Berkurangnya kewaspadaan terhadap
lingkungan sekitarnya.
3. Derealisasi.
4. Depersonalisasi.
5. Amnesia disosiativ (ketidakmampuan utk
mengingat kembali aspek penting dari trauma).
C. Pengulangan kembali yang menetap dari peristiwa
traumatik melalui cara berikut; pengulangan
bayanganpikiran-pikiran, mimpi, episode
flashback, atau perasaan berada peristiwa
traumatik atau penderitaan ok terpapar peristiwa
traumatik.
 Lanjutan......
D. Penghindaran sekumpulan rangsang yang
membangkitkan peristiwa traumatik (c/. Pikiran,
perasaan, pembicaraan, aktifitas, tempat dll).

E. Gejala-gejala yang jelas dari kecemasan atau

meningkatnya bangkitan (c/ sulit tidur, mudah
marah, sulit utk konsentrasi, terkejut berlebihan,
kegelisahan motorik).
 Lanjutan.....
F. Gangguan signifikan secara klinis mengakibatkan
penderitaan atau hendaya sosial, pekerjaan atau
fungsi penting lainnya atau hendaya utk
menyelesaikan berbagai tugas spt mendapatkan
bantuan penting atau menggerakkan sumberdaya
melalui pembicaraan dengan anggota keluarga ttg
pengalaman traumatik.

G. Gangguan dan terjadi dala 4 minggu peristiwa

traumatik.
 Lanjutan.......
H. Gangguan tidak disebabkan ok efek fisiologis
langsung dari zat ( c/ penyalahgunaan zat,
pengobatan) atau kondisi medik umum, tidak ter-
masuk dalam kelompok Gangguan Psikotik .

Bedanya PTSD dgn Gangguan Stres Akut adalah

bahwa pd Ggn Stres Akut gejala berakhir setelah 2
hari peristiwa traumatis atau sebelum 4 minggu.
 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
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 delirium
D. 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 (Ectasy).

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