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Kelompok Tutorial B10



Lembar Pertama

Seorang pria,30 tahun datang ke pratek dokter

dengan rasa cemas berlebihan.Hal ini sebenarnyasudah dialaminya sejak tujuh bulan yang lalu.Ia

yang bekerja sebagai tenaga akuntan di suatu

perusahan swasta terkemuka merasa khawatir

kinerjanya menurun,sering merasa terperangkap

(feeling keyed up) di pekerjaan. Ia menjadi mudah

lelah,sulit konsentrasi, merasa,mudah tersinggung

dan ketegangan otot. Gejala tersebut juga disertai

jantung berdebar-debar,keringat berlebihan dan

mulas-mulas



Lembar kedua

Dari hasil pemeriksaan diperolehi:

Status Presens:Sensorium: Compos Mentis,TD:120/80

mmHg,Nadi:96x/menit,

Pernafasan: 20x/menit,Suhu tubuh normal.Hasil

pemeriksaanlaboratorium: darah dan urine rutin normal T3 dan T4:

dalam

batas normal. EEG dalam batas normal

Lembar Ketiga

Dua-tiga kali dalam sebulan pria itu menggunakan ecstasy

saat berkumpul dengan teman-temannya di café.Ia juga

mengkonsumsi rokok dan alkohol saat berusia 18-21



HIPOTESA

Generalized Anxiety Disorder

Withdrawal Syndrome

Drug Induced Anxiety

Drug abuse Drug + Anxiety



Learning Issue

Anxiety Definisi fisiologis dan patologis

Etiologi dan patofisiologi

Klasifikasi

Diagnosis, Gejala klinis

Differensial diagnosa

Penatalaksanaan

Prognosis,komplikasi,SKDIPengaruh obat/zat pada anxiety

Definisi drug abuse,drug misuse,drug addiction.drug

tolenrance

Penanganan obat atau zat



Anxiety



Definisi ansiatas fisiologis

• Threatening situation---- response

• Feelings of apprehension

• Pysiological response--- defence @ escape• Fight or flight

• Increased sympathethic nervous system

* Attention: focus on situation



Definisi ansiatas patologis

Response Out of proportion

Prolonged

No threat

Symptoms: same* Attention : focus on physiological response, NOT

on the threatening situation



Etiologi

Predisposing factors Genetic

Childhood upbringing

Personality type ( anxious and worry prone)

Precipitating factots

Stressful events

Threatening events



Maintaining factors Continuous stressful events

Ways of thinking

Kl ifik i



KlasifikasiDSM IV-TR

Panic Disorders

Agoraphobia

Social phobia

Specific Phobia OCD

PTSD & Acute Stress Disorder

Separation anxiety



Panic Disorder & Agoraphobia

12

An acute intense attack of anxietyaccompanied by feelings of impendingdoom is known as panic disorder

The anxiety is characterized by discreteperiods of intense fear that can vary fromseveral attacks during one day to only afew attacks during a year

Patients with panic disorder present with anumber of comorbid conditions, mostcommonly agoraphobia, which refers to afear of or anxiety regarding places fromwhich escape might be difficult



- - Attack

13

A discrete period of intense fear or discomfort,in which four (or more) of thefollowing symptoms developed abruptly &reached a peak within 10 minutes :

1.palpitations, pounding heart, or accelerated heart beat

2. sweating

3. trembling or shaking

4. sensations of shortness of breath or smothering

5. feeling of choking

6.chest pain or discomfort



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7. nausea or abdominal distress

8. feeling dizzy, unsteady, lightheaded or

faint

9. derealization (feelings of unreality) or

depersonalization ( being detached from

one self) 10. fear of losing control or going crazy

11. fear of dying

12. paresthesias ( numbness or tingling

sensations)

13. chills or hot flushes



15

The DSM-IV-TR contains 2 diagnostic criteria for

panic disorder, one without agoraphobia and the

other with agoraphobia, but both require the

presence of panic attacks

Panic attacks can occur in mental disorders other

than panic disorder, particularly in specific phobia,

social phobia & PTSD Unexpected panic attacks occur at any time & are

not associated with any identifiable situational

stimulus, but panic attacks need not be

unexpected Attacks in patients with social & specific phobias

are usually expected or cued to a recognized or

specific stimulus



16

Some panic attacks do not fit easily into

the distinction between unexpected &

expected, and these attacks are referred to

as situationally predisposed panic attacks



DSM- IV- TR Criteria for Agoraphobia

17

A. Anxiety about being in places or situations from which escape might bedifficult(or embarassing)or in which helpmay not be available in the event of having

an unexpected or situationallypredisposed panic attack or panic-likesymptoms. Agoraphobic fears typicallyinvolve characteristic clusters of

situations that include being outside thehome alone; being in a crowd or standingin a line; being on a bridge & traveling in abus, train or automobile



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B. The situations 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 symptoms, or require the

presence of a companion

C. The anxiety or phobic avoidance is not

better accounted for by another mentaldisorder , such as social phobia (e.g.,

avoidance limited to social situations because

of fear of embarassment), specific phobia

(e.g., avoidance limited to a single situationlike elevators), obsessive compulsive disorder

( avoidance of dirt), posttraumatic stress

disorder ( avoidance of stimuli associated with

a severe stressor) or separation anxiety



Specific Phobia & Social Phobia

19

Phobia : an excessive fear of a specific object,circumstance or situation

Specific phobia : strong, persisting fear of an

object or situation

Social phobia :strong, persisting fear of situations

in which embarassment can occur

The diagnosis of both specific & social phobia

requires the development of intense anxiety, evento the point of panic, when exposed to the feared

situations



Specific Phobia

20

More common than social phobia

May anticipate harm, such as being bitten by a

dog, may panic at thought of losing control if they

fear being in an elevator

The peak age of onset for the natural

environment type & blood-injection-injury-type : 5-

9 years

Onset for situational type (except fear of heights):mid 20s

The feared objects & situations in specific phobia

(listed in descending frequency of appearance)

are animals, storms, heights, illness, injury &



Social Phobia= Social Anxiety

Disorder

21

Have excessive fears of humiliation or embarassment in various social settings, such as

speaking in public, urinating in public rest room

(‘shy bladder”) &speaking to a date



Obsessive Compulsive Disorder

(OCD)

22

Represented by a diverse group of symptoms that

include intrusive thoughts, rituals, preoccupation

& compulsions

These recurrent obsessions or compulsionscause severe distress to the person

The obsessions or compulsions are time –

consuming & interfere significantly with the

person’s normal routine, occupational functioning,

usual social activities or relationships

A patient with OCD may have an obsession, a

compulsion or both



23

Obsession : a recurrent & intrusive thought,

feeling, idea or sensation

Compulsion : a behavior Specifically, a compulsion is a conscious,

standardized, recurrent behavior, such as

counting, checking, or avoiding

A patient with OCD realizes the irrationality of theobsession & experiences both the obsession &

the compulsion as ego-dystonic (unwnted

behavior)



OCD has 4 major symptom pattern :

24

1. Contamination

2. Pathological doubt

3. Intrusive thoughts

4. Symmetry



Obsessions

25

Contamination

Pathological doubt

Somatic

Need for symmetry Aggressive

Sexual

Other

Multiple obsessions



Compulsions

26

Checking

Washing

Counting

Need to ask or confess Symmetry and precision

Hoarding

Multiple comparisons



Treatment

27

Pharmacotherapy : SSRI, clomipramine

Behavior therapy : desensitization,thought

stopping,flooding,implosion therapy & aversive

conditioning

Psychotherapy



Posttraumatic Stress Disorder

(PTSD)& Acute Stress Disorder

28

Condition marked by the development of

symptoms after exposure to traumatic life events

The person reacts to this experience with fear &

helplessness, persistently relives the event, &tries to avoid being reminded of it

PTSD :The symptom must last for more than a

month after the event & must significantly affect

important areas of life, such as family & work

Acute stress disorder : occurs earlier than PTSD;

within 4 weeks of the event, & remits within 2days

to 4 weeks



29

The stressors causing both acute stress disorder

& PTSD are sufficiently overwhelming to affect

almost anyone They can arise from experiences in war, torture,

natural catatstrophes, assault, rape & serious

accidents, for example, in cars & in burning

buildings The DSM-IV-TR diagnostic criteria for PTSD

specify that the symptoms of experiencing,

avoidance & hyperarousal must have lasted more

than 1 month ;acute : if the symptoms have lastedless than 3 months, chronic : if the symptoms

have lasted than 3 months or more



Clinical Features of PTSD

30

Painful reexperiencing of the event, a pattern of avoidance & emotional numbing, fairly constant

hyperarousal

The disorder may not develop until months or

even years after the event

The mental status examination often reveals

feelings of guilt, rejection & humiliation

Patients may also describe dissociative states &panic attacks, illusions & hallucinations may be

present



Treatment

31

Pharmacotherapy : SSRI : sertraline, paroxetine Psychotherapy : psychodynamic psychotherapy,

crisis intervention with support, education &

development of coping mechanism & acceptance

of the event




32

Excessive anxiety & worry about several eventsor activities for most days during at least 6- month

period

The worry is difficult to control and is associated

with somatic symptoms, such as muscle tension,irritability, difficulty sleeping & restlessness

Anxiety is not focused on features of another axis

I disorder, not caused by substance use or a

general medical condition& does not occur only

during a mood or psychiatric disorder

Anxiety is difficult to control, is subjectively

distressing & produces impairment in important

areas of a erson’s life



DSM-IV_TR Diagnostic Criteria for


33

A. Excessive anxiety & worry occurring moredays than not for at least 6 months, about a

number of events or activities (such as work or

school performance)

B. The person finds it difficult to control the worry



34

C. The anxiety & worry are associated with 3 or

more of the following 6 symptoms (with at least

some symptoms present for more days than not

for the past 6 months)

1. restlessness or feeling keyed up or on edge

2. being easily fatigue

3. difficulty concentrating or mind going blank 4. irritability

5. muscle tension

6. sleep disturbance ( difficulty falling or staying

asleep, or restless unsatisfying sleep)



35

D. The focus of the anxiety & worry is not

confined to features of an axis I disorder

E. The anxiety, worry or physical symptomscause clinically significant distress or impairment

in social, occupational or other important areas of

functioning

The disturbance is not due to the directphysiological effects of a substance or a general

medical condition and does not occur exclusively

during a mood disorder, a psychotic disorder or a

pervasive developmental disorder



Gejala Klinis dan Diagnosa

Jika terdapat >3 gejala dibawah akan di diagnosasebagai ansietas

Berlebihan kekhawatiran, dan ketegangan yang sedang berlangsung

Suatu pandangan yang tidak realistis dari masalah

Gelisah

sifat lekas marah

ketegangan otot

sakit kepala

berkeringat

kesulitan berkonsentrasi mual

Kebutuhan untuk pergi ke kamar mandi sering

kelelahan

Kesulitan jatuh atau tetap tidur

Gemetaran

Menjadi mudah kaget



Pemeriksaan Penunjang

Tiada pemeriksaan penunjang untuk ansietas.Pemeriksaan

hanya di lakukan untuk menyingkirkan diagnosa

banding

Pemeriksaan lab:

Darah lengkap,Tes fungsi tirod, urinalisis,analisa

gas darah

Exclude mental disorder: EEG,LP,CT-scan

Exclude cardio disease:

EKG



Differensial diagnosa

Oppositional defiant disorder

Peptic ulcer disease Avoidant personality

Hypochondriasis

Social phobia and selective mutism

Specific phobia

Trichotillomania Asthma

Depression

Dysthymic disorder

Obstructive sleep apnea syndrome Somatization

Panic disorder

Substance abuse, including caffeine and tobacco



Penatalaksanaan

FarmakologiBenzodiazepin:

diazepam,larazepam,prazepam,halozepam,

KlorazepamBuspiron (5-HT)

SSRI (Selective serotonin reuptake inhibitor):

Sertaline,paroxetine



Non farmakologi

Education Educates about GAD, including

common worries and bodilysymptoms .

Recommends relevant self-help

reading materials (for example,

Hazlett-Stevens H. Women who

wor ry too much: how to stop wo r ry

& anxiety from ru in ing

relat ions hip s, work, & fun . Oakland

(CA): New Harbinger Publications;

2005)

Cognitive interventions Reappraise unrealistic beliefs

concerning the value of worryWork on realistic estimation of

likelihood of negative outcome

occurring and evaluation of the harm

caused by these events Deal with

problems related to intolerance of

uncertainty and perfectionism.



Exposure Offers imaginal exposure to worry-

related imagery and feared

catastrophes (for example, illnessor death of a family member,

financial disaster, or failure at work

or school)

Involves learning to tolerate, rather

than avoid, anxiety-relatedexperiences.

Emotion-regulation

approaches

Teach relaxation strategies .

Work on acceptance of anxiety,

mindfulness-based meditation



Problem solving Individuals with GAD may respond

to a wide range of challenges by

worrying, with little effort focused

on problem solving; develops

stronger problem-solving skills that

may provide a more

appropriate response to these

challenges

Focuses on goals and direction inlife, planning enjoyable activities,

activities to increase sense

of psychological well-being

Relapse prevention Prepares for periods of increased

anxiety when exposed to threatening

experiences that relate to the theme of the worries (for example, family

member with serious illness, financial

threat).



Komplikasi

• Substance abuse• Depresi

• HTN

• Headache

• Bruxism

• Imun

• Amenorea

• GI

• Sleep disorder

• Sosial



Prognosis

Umumnya hilang gejala setelah terapi minggusampai bulan. Tergantung onset, keberadaan

komplikasi, dan kooperasi pasien

SKDI Anxiety

Withdrawal3A



Pengaruh obat/zat pada anxiety



Alkohol

Pada alkoholism, mereka beranggapan bahwaansietas merupakan hal dasar mereka untuk

konsumsi alkohol, tapi menurut riset yang

dilakukan, mengkonsumsi alkohol bisa

menimbulkan ansietas. Alkohol bisa memberi dampak buruk bagi tubuh

seperti sirosis hepatis.

Jika terjadi keadaan putus zat, maka akan timbul

kejang dan delirium trimens.



Kanabis

Reseptor kanabinoid terdapat di ganglia basalis,hipokampus, serebellum, korteks serebri.

Mempengaruhi monoamin dan asam gamma

aminobutirat.

Jika terjadi putus zat, maka menimbulkan gelisah,

insomnia, anoreksia, mual.

Berhubungan dengan terjadinya ansietas.



Zat Inhalan

Contoh: lem, bensin, penghapus. Merupakan depresan SSP.

Jika terjadi putus zat, maka efek yang timbul

adalah gangguan tidur, gugup, mual muntah,

takikardi, halusinasi.

Dapat menimbulkan gangguan delirium,

dimensia, psikotik, mood, dan ansietas.



Fensiklidin

Merupakan zat anastetik disosiatif. Mencegah influks ion kalsium, mengaktivasi

neuron dopaminergik pada area tegmental

ventral, yang berjalan ke korteks serebri dan

sistem limbik.



Definisi

DRUG ABUSE : penggunaan obat secara tanparesep dokter dan non-medical purposes

Contoh : obat SSP seperti narkoba

untuk olahraga seperti doping

DRUG MISUSE : penggunan obat secara indikasi

salah,dosis salah dan lama pemberian salah

Contoh : amoksisilin 500 mg,diberi untukinfluenza,dengan dosis 2 kali sehari selama 10

hari.



DRUG TOLERANCE : a condition of cellular to apharmacologically active substance so that

increasingly larger doses are required to produce

the same physiologic effect obtained earlier with

smaller doses.

DRUG ADDICTION : substance dependence or

chemical dependence :is a disease characterized

by a destrucyive pattern of drug that leads tosignificant problems involving tolerance to or

withdrawal from the substance as well as other

problems.



Penanganan obat atau zat



USAHA PREVENSI :

Memberikan informasi

Membuat forum komunikasi dan konsultasi,

semibar, kursus, ceramah, dsb.

USAHA REPRESI :

Pencarian tempat tanaman & sumber bahan /

obat tersebut dimusnahkan.

Pengedarnya dituntut ke pengadilan.

Pemakainya bila perlu diberi pengobatan.



Kesimpulan

Pria tersebut mengalami Generalised AnxietyDisorder dan drug dependency

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