BACK FROM BEHAVIOR TO

MOLLECULAR EXPRESSION

RONNY TRI WIRASTO,M.D, Psychiatrist

Dept Of Psychiatry
Medical School Gadjah Mada University
Learning Objectives
After completing this session, the students should be
able to :
1. Understand the neuro-psycho-pathology of anxiety
disorder
2. Understand the characteristic of anxiety disorder
3. Conclude the relation between psychological and
environmental factors with anxiety disorder
4. Understand the management of anxiety disorder
Epidemiology
 United State :
 The National Comorbidity Study reported that one in four persons
met the diagnostic criteria for at least one anxiety disorder
 Anxiety disorders have a 12-month prevalence rate of17.7
percent.
 Women have a lifetime prevalence of 30.5 percent versus 19.2
percent prevalence in men.
 Prevalence of anxiety disorders decreases with higher
socioeconomic status.
 Indonesia (2001)
 6 Million people, and 5,5 milllion get no treatment
CAUSES
Causes…
For many years :
 Abnormal behavior
 Fight VS Flight
 Emotion feeling
 Reactions of a perceived threat
 Fear
 Etc…..
Cause
There are 4 processes due to anxiety
 Genetic

dopamine catabolic enzyme catechol-O-methyltransferase (COMT Val158Met)

5-GGGCCTACTGTGGCTACTCA-3
Anxiety Vulnerability
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.
 Diarrhea
 Dizziness, lightheadedness
 Hyperhydrosis
 Hyperreflexia
 Palpitations
 Pupillary mydriasis
 Restlessness
 Syncope
 Tachycardia
 Tingling in the
 extremities
 Tremors
 Upset stomach
 Urinary Frequency
Differential Diagnosis for Anxiety
Disorders
•Cardiovascular/Respiratory •Gastrointestinal
Disorders • Colitis
• Arrhythmias • Irritable Bowel Syndrome
• COPD • Peptic ulcers
• Hypertension • Ulcerative colitis
• Angina • Miscellaneous
• Myocardial Infarction • Epilepsy
• Endocrine system • Migraine
• Hyperthyroidism • Pain
• Hypothyroidism • Pernicious anemia
• Hypoglycemia • Porphyria
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 • Fear of going crazy or
distress 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

*courtesy BBC