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AGORAPHOBIA

A. Etiology and Pathogenesis


1. Personality
Behavioral inhibition
Neuroticism is long-term tendency to respond with negative emotions to

threat, frustration, or loss


Anxiety sensitivity is the disposition belief that symptoms of anxiety are

harmful
2. Enviromental
Negative events in childhood and other stressful events such as

separation or death of parents, being attacker or mugeed


Increased overprotection in the child-rearing behavior
Repressed hostility, rage, or sexuality projected on environment, which is

seen as dangerous
3. Genetic and Physiological
Heritability is 61%. Of the various phobias, it is the strongest and most
spesific association with genetic factors
B. Epidemiology
1. Prevalence
The prevalence ranges from 30% in community to more than 50% in clinic
2. Age
Mean age at onset is 17 years. But, it also can be 25 29 years, before age
35 years, or after age 40 years
3. Course
Typically persistent and chronic, complete remission is rare
In United States, it always develops as complication of panic disorder
C. Gejala Klinis
Menghindari situasi dimana sulit mendapatkan bantuan
Lebih suka ditemani saat pergi ke tempat tertentu misalnya jalan yang ramai,

toko yang padat, ruangan tertutup seperti lift, kendaraan tertutup seperti bus
Meminta untuk ditemani saat keluar rumah, bahkan jika parah maka hanya

berdiam diri di rumah (housebond) dan tidak mau bekerja


F40.0 Diagnostic Criteria for Agoraphobia (DSM-V)
a. Marked fear or anxiety about two or more of the following
situations
Using public transportations such as automobiles, buses, trains,
ships
Being in open spaces such as parking lots, marketplaces, bridges
Being in enclosed places such as shops, theathers, cinemas
Standing in line or being in crowd
Being outside of the home alone
b. The individual fears or avoids these situations because of thoughts

c.
d.
e.
f.
g.

h.
i.

that escape might be difficult or help might not be available in the


event of developing panic-like symptoms or other incapacitating or
embarrasing symptoms
The agoraphobic situations almost always provoke fear or anxiety
The agoraphobic situations are actively avoided, require the
presence of companion, or are endured with intense fear or anxiety
The fear or anxiety is out of proportion to the actual danger posed
by the agoraphobic situations and to the sociocultural context
The fear, anxiety, or avoidance is persistent lasting for 6 months or
more
The fear, anxiety, or avoidance causes clinically significant distress
or impairment in social, occupational, or other important areas of
functioning
If another medical condition such as IBD or Parkinsons disease is
present, the fear, anxiety, or avoidance is clearly excessive
The fear, anxiety, or avoidance is not better explained by the
symptoms of another mental disorder, and are not related
exclusively to obsessions, perceived defects or flaws in physical
appearance, reminders of traumatic events, or fear of separation

D. Therapy
1. Pharmacologic Therapy
Benzodiazepine has the most rapid onset of action. Alprazolam and

lorazepam are the most commonly prescribed. Long-term use is fraught


with the dependence, cognitive impairment, and tolerance
SSRI are currently drugs of choice with paroxetine being the most widely

used
Tricyclic and tetracyclic drugs such as clomipramine and imipramine
2. Psychotherapy
Supportive psychotherapy involve the use of psychodynamic concepts and

therapeutic alliance to promote adaptive coping


Behavior therapy with positive and negative reinforcement, systematic

desensitization, flooding, implosion, graded exposure, response


prevention, stop thought, relaxation techniques
Cognitive therapy is based on the premise that maladaptive behavior is

secondary to distortions in how people perceive themselves and in how


other perceive them
Virtual therapy with computer programs that allow patients to see
themselves as avatars who are then placed in open or crowded spaces

PHOBIA SOSIAL
A. Etiology and Pathogenesis

1. Psychologic Factors
Trait of behavioral inhibiton and fear of negative evaluation
Childhood maltreatment and adversity
The parents were less caring, more rejecting, and more overprotective
2. Genetic Factors
The genetic influence is subject to gene-environment influences
First-degree relatives are about three times more likely to be affected
3. Biology Factors
Release norepinephrine or epinephrine both centrally and peripherally
Decreased dopamine activity and low levels of homovanillic acid
B. Epidemiology
1. Prevalence
Lifetime prevalence ranging from 3 13%
2. Age and Sex
Mean age at onset between 8 15 years, the peak is in the teens
May follow stressful or humiliating experience such as being bullied,

vomiting during public speaking


First onset in adulthood is relatively rare and is more likely to occur after

new job promotion and marrying someone from different social class
3. Course
Typically persistent and chronic, complete remission is rare
C. Clinical Features
Irrational fear of performing activities in the presence of other people
Thought that they will be judged as anxious, weak, crazy, stupid, boring,

intimidating, dirty, or unlikable


Fears that they will act or appear in certain way or show anxiety symptoms
Rigid body posture, inadequate eye contact, less open in conversation, highly

controlled speak, soft voice


May seek employment in jobs that do not require social contact, men may be

delayed in marrying, women may live as homemaker


F40.1 Diagnostic Criteria for Social Phobia (DSM-V)
a. Marked fear or anxiety about one or more social situations in which
the individual is exposed to possible scrutiny by others
Social interactions : Having conversation, meeting unfamiliar

people
Being observed : Eating or drinking
Performing in front of others : Giving public speech

In children, the anxiety must occur in peer settings and not just
during interaction with adults
b. The individual fears that he or she will act in way or show anxiety
symptoms that will be negatively evaluated (humiliating,
embarrasing, rejection, offend others)
c. The social situations almost always provoke fear or anxiety
In children, the fear or anxiety may be expressed by crying,

d.
e.
f.
g.

h.
i.
j.

tantrums, freezing, clinging, shrinking, or failing to speak in social


situations
The social situations are avoided or endured with intense fear or
anxiety
The fear or anxiety is out of proportion to the actual threat posed
by social situation and to the sociocultural context
The fear, anxiety, or avoidance is persistent, lasting for 6 months or
more
The fear, anxiety, or avoidance causes clinically significant distress
or impairment in social, occupational, or other important area of
functioning
The fear, anxiety, or avoidance is not attributable to the
physiological effects of substances or another medical condition
The fear, anxiety, or avoidance is not better explained by symptoms
of other mental disorder
If another medical condition is present, the fear, anxiety, or
avoidance is clearly unrelatedor is excessive

D. Therapy
1. Pharmacologic Therapy
SSRI is considered the first-line treatment. Others are benzodiazepine,

venlafaxine, buspirone
MAO-I for severe cases such as phenelzine, moclobemide
Beta blockers shortly before exposure. The most widely used are atenolol

or pronanolol, which taken about 1 hour before performance


2. Psychotherapy
Combination of behavioral and cognitive methods including cognitive
retraining, desensitization, rehearsal during sessions, homework assignments

PHOBIA KHAS / SPESIFIK


A. Etiology and Pathogenesis
1. Psychodynamic Theories
a. Repression and displacement
Id impulse are repressed into unconscious state Anxiety Repression
fails to function Displaced on to neutral object or situation
b. Symbolization
The phobic object or situation may have direct association with primary
source of conflict
c. Unresolved Conflict in Oediphal Stage
The conflict concerns the sexual impulses that the child has toward the
parent of the opposite gender and the hostile impulses that the child has
towards the parent of the same gender
2. Behavioral Theories

a. Classical Conditioning
Anxiety is provoked by naturally frightening stimulus that occurs in

contiguity with second inherently neutral stimulus


For example, Albert is stimulated by rat (neutral stimulus) in

association with loud noise (unconditioned stimulus) He


automaticully feared the loud noise and quickly learned to fear the rat
b. Operant Conditioning
Individuals learn that their fear is reduced by avoiding the stimulus
Every time individuals avoid the phobic stimulus, they are rewarded by
the relief from anxiety
c. Social Learning
Phobias could be developed through observational learning, modelling,

and direct reinforcement


If the observer is a young child, the model may be the mother or father
For example, the child see that the mother reacts with high emotion

when there is large spider in the bath The child may develop
arachnophobia
3. Environmental Factors
Parental overprotectiveness, parental loss and separation
Physical and sexual abuse
Negative or traumatic encounters with feared object or situation
4. Genetic Factors
Certain category of spesific phobia tends to run in families
First-degree relatives of individual with animals phobia is more likely to

have the same spesific animal phobia than any category of phobia
Individual with blood-injection-injury phobia show unique propensity to

vasovagal syncope in the presence of phobic stimulus


B. Epidemiology
1. Prevalence
The most common mental disorders in the United States
The lifetime prevalence is about 10%
2. Age
The peak age of onset for natural environment and blood-injection-injury

spesific phobia is in 5 9 years


The peak age of onset for situational spesific phobia is in the mid of 20

years
3. Sex
Women is affected two times higher than men
4. Kinds of Phobia
Arachnophobia (spider) > Astraphobia (lightning) > Acrophobia (height) >
Nosophobia (illness) > Traumatophobia (injury) > Necrophobia (death)
C. Clinical Features
Arousal of anxiety when the persons are exposed to spesific objects or

situations
Try to avoid the phobic stimulus Persistent avoidance behavior

The fear is out of proportion to danger perceived, patient recognises the fear

as irrational and unjustified


Phobia or phobic object gradually become preoccupation with patient which

a.

b.
c.
d.
e.
f.

g.

result in marked distress and restriction of freedom of mobility


F40.2 Diagnostic Criteria for Specific Phobia (DSM-V)
Marked fear or anxiety about specific object or situation such as
flying, heights, animals, receiving an injection, seeing blood
In children, the fear or anxiety may be expressed by crying,
tantrums, freezing, or clinging
The phobic object or situation always provokes immediate fear or
anxiety
The phobic object or situation is actively avoided or endured with
intense fear or anxiety
The fear of anxiety is out of proportion to the actual danger posed
by spesific object or situation and sociocultural context
The fear, anxiety, or avoidance is persistent, lasting for 6 months or
more
The fear, anxiety, or avoidance causes clinically significant distress
or impairment in social, occupational, or other important area of
functioning
The fear, anxiety, or avoidance is not better explained by symptoms
of other mental disorder

D. Psychotherapy with Exposure Therapy


Patients is desensitized by using series of gradual, self-paced exposure to the

phobic stimuli
Teach various techniques to deal with anxiety including relaxation, breathing

control, and cognitive approach


The cognitive approach include reinforcing the realization that the phobic
objects or situations is, in fact, safe

GANGGUAN PANIK
A. Etiology and Pathogenesis
1. Biologic Factors
Exaggerated postsynaptic receptor response to serotonin
Decreased inhibitory GABA receptor sensitivity with resultant excitatory

effect
Increased local norepinephrine discharge with hypersensitivity of

presynaptic alpha-2-receptors
Increased sympathetic tone which adapt slowly to repeated stimuli and

respond excessively to moderate stimuli


2. Neuroanatomic Models

Mediated by fear network in the brain that involves the amygdala, the

hypothalamus, and brainstem centers


Cortical atrophy in right temporal lobe
Dysregulation of cerebral blood flow, cerebral vasoconstriction
3. Genetic Factors
First-degree relatives are about four to eight times more likely to be

affected
Increased risk for panic disorder among relatives of parents with anxiety,

depression, and bipolar disorders


4. Psychodynamic Factors
Unsuccessful defense against anxiety-provoking impulses
Previously mild anxiety signal becomes overwhelming feeling of

apprehension, complete with somatic symptoms


Physical or emotional separation from significant person both in childhood

and in adult life, childhood experience of physical or sexual abuse


Difficulty in tolerating anger and unconscious fantasy, negative affectivity

and anxiety sensitivity


B. Epidemiology
1. Prevalence
The lifetime prevalence in United States and European is 2 3%
Significantly lower rates among Latinos, African Americans, Caribbean
blacks, and Asian Americans
American Indians, by contrast, have significantly higher rates
2. Age
Most commonly develop in young adulthood, mean age at onset 25 years
Low before age 14 years, increase during adolescence, peak during
adulthood, and decline in older individual
3. Sex
Women are two to three times more likely to be affected than men
4. Course
Chronic with remissions and exacerbations
The attacks can occur several times in day, two or three times a week, or

less than once a month


In the first one or two attacks, patients may be relatively unconcerned.

With repeated attacks, the symptoms may become major concern


C. Gejala Klinis
Serangan terjadi secara spontan dan berulang Khawatir mengalami

kembali kondisi tersebut (anticipatory anxiety)


Dimulai selama 10 menit, gejala meningkat secara cepat, dan mirip dengan

gangguan jantung
Pernapasan terasa cepat dan pendek, tetapi tidak terdapat bukti

hiperventilasi
Merasa sangat takut, ancaman kematian, bingung, sulit konsentrasi

Sulit berbicara (gagap), gangguan memori, depresi, derealisasi,

depersonalisasi
Nocturnal panic attack : Serangan panik pada malam hari yang

membangunkan pasien dari tidur


F41.0 Diagnostic Criteria for Panic Disorder (DSM-V)
a. Recurrent unexpected panic attacks. Panic attack is abrupt surge of
intense fear or intense discomfort that reaches peak within
minutes, and during which time four or more of the following
symptoms occur :
Palpitations, pounding hear, or accelerated heart rate
Sweating
Trembling or shaking
Sensations of shortness of breath or smothering
Feelings of choking
Chest pain or discomfort
Nausea or abdominal distress
Feeling dizzy, unsteady, light-headed, or faint
Chills or heat sensations
Paresthesias : Numbness or tingling sensations
Derealization or depersonalization
Feeling of losing control or going crazy
Fear of dying
Culture-spesific symptoms (tinnitus, neck soreness, headache,
uncontrollabel screaming or crying) may be seen. Such symptoms
should not count as one of four required symptoms
b. At least one of the attacks has been followed by 1 month or more of
one or both of the following
Persistent concern or worry about additional panic attack or their

consequences
Significant maladaptive change in behavior related to the attacks

such as avoidance of exercise or unfamiliar situations


c. The disturbance is not attributable to the physiologic effects of
substance or another medical condition
d. The disturbance is not better explained by another mental disorder
D. Terapi
1. Terapi Farmakologi
SSRI (paroxetine) diberikan selama 3 6 bulan
Alprazolam diberikan selama 4 6 minggu kemudian dosis diturunkan
secara perlahan sampai akhirnya dihentikan dan hanya mengonsumsi
SSRI
2. Psikoterapi
a. Terapi Relaksasi

Melatih pernapasan dengan menarik napas dalam kemudian

mengeluarkan secara lambat


Relaksasi semua otot tubuh
Sugesti pikiran ke arah konstruktif atau yang diinginkan akan dicapai
b. Terapi Kognitif Perilaku
Rekonstruksi pikiran dengan membentuk kembali pola pikir dan

perilaku yang irrasional menjadi pikiran yang rasional


Diberikan pekerjaan rumah berupa menulis daftar pengalaman harian

dalam menyikapi berbagai peristiwa


c. Terapi Psikodinamik
Seseorang diajak untuk memahami diri dan kepribadiannya secara lebih
mendalam, tidak hanya menghilangkan gejala

GANGGUAN CEMAS MENYELURUH


A. Etiology and Pathogenesis
1. Biologic Factors
Decreased inhibitory neurotransmission, increased excitatory

neurotransmission, or combination of these two processes


GABA receptors is downregulated, especially in occipital lobe which has

the highest levels of benzodiazepine receptors


Abnormal regulation of serotonine, subsensitivity of -adrenergic

receptors, hypersensitive to cholecystokinin


Brain areas hypothesized to be involved are occipital lobe, basal ganglia,

limbic system, and frontal cortex


2. Psychodynamic Theories
Unresolved, unconscious conflicts which are related to separation or loss

of loved things or fear of disappointed himself with moral value and


opinion
Respond to incorrectly and inaccurately perceived dangers. Inaccuracy is

generated by attention to negative details in environment, by distortions


in information processing, and by overly negative view of coping ability
Behavioral inhibition, negative affectivity, harm avoidance
B. Epidemiology
1. Prevalence
It is common condition with lifetime prevalence is 5 8%
More frequent in European descent
2. Age
The onset is in late adolescence or early adulthood, peak in middle age, and
declines in elderly
3. Sex
Females are twice as likely as males
4. Course

Chronic, feeling anxious and nervous all of their lives, wash and wane

across lifespan, symptoms may diminish as the patient gets older


In children and adolescent, thre may be excessive concerns about

punctuality and catastrophic events such as earthquakes or nuclear war


With time, secondary depression may develop
C. Clinical Features
1. General Symptoms
Sustained and excessive anxiety and worry accompanied by physical

symptoms which prevent them from enjoying life


Prone to feeling restless, keyed up much of the time, difficult to

concentrate, feeling that their mind goes blank


Difficult to fall or stay asleep but feel fatigued, irritable, and tense in the

day
2. Motoric Symptoms
Trembling, twitching, feeling shaky, muscles aches or soreness
3. Autonomic Hypereactivity
Accelerated heart rate, shortness of breath, dizziness, chronic diarrhea,
sweating
4. Exaggerated startle response
F41.1 Diagnostic Criteria for Generalized Anxiety Disorder (DSM-V)
a. Excessive anxiety and worry (apprehensive expectation), occuring
more days than not for at least 6 months, about number of events
or activities such as work or school performance
b. The individual finds it difficult to control the worry
c. The anxiety and worry are associated with three or more of
following symptoms with at least some symptoms having been
present for more days than not for the past 6 months :
Restlessness or feeling keyed up or on edge
Being easily fatigued
Difficulty concentrating or mind going blank
Irritability
Muscle tension
Sleep disturbance : Difficulty falling asleep, or restless,
unsatisfying sleep
d. The anxiety, worry, or physical symptoms cause clinically significant
distress or impairment in social, occipational, or other important
areas of functioning
e. The disturbance is not attributable to the physiological effects of
substance or another medical condition
f. The disturbance is not better explained by another mental disorder
D. Terapi
1. Terapi Farmakologi

Benzodiazepine merupakan first-line drugs. Dimulai dari dosis rendah

kemudian ditingkatkan sampai mencapai dosis terapi selama 2 6 minggu


dilanjutkan dengan tapering off selama 1 2 minggu
Buspiron lebih efektif untuk memperbaiki gejala kognitif. Tidak

menyebabkan withdrawal tetapi efeknya baru muncul setelah 2 3


minggu
SSRI (sertraline, citalopram, paroxetine) jika disertai dengan gejala depresi
2. Psikoterapi
a. Terapi Kognitif Perilaku
Pendekatan kognitif mengajak pasien untuk mengenali distorsi pikiran
Pendekatan perilaku mengajak pasien untuk mengenali gejala somatik
Teknik utama yang digunakan adalah relaksasi dan biofeedback
b. Terapi Suportif
Pasien diberikan reassurance dan kenyamanan, menggali potensi dan
bakat terpendam, mendukung ego sehingga dapat beradaptasi dalam
fungsi sosial dan pekerjaan
c. Insight-oriented Therapy
Mengajak pasien untuk menyingkap konflik bawah sadar, menilik
kekuatan ego, relasi objek, dan keutuhan diri
GANGGUAN OBSESIF KOMPULSIF
A. Etiologi
1. Faktor Biologi
Gangguan pada neurotransmitter serotonin dan norepinefrin
Riwayat infeksi Streptococcus yang menyebabkan demam rematik
Peningkatan aktivitas pada lobus frontalis, ganglia basalis terutama
nucleus caudatus, dan cingulum
2. Psychologic Factors
Greater internalizing symptoms, higher negative emotion, behavioral

inhibition in childhood
Physical and sexual abuse in childhood, other stressful or traumatic events
Regression from oediphal phase to the anal phase Feel threatened by

anxiety Intensely ambivalent emotion Experience both love and hate


toward object Doing and undoing behavior
3. Behavioral Factors
Classical conditioning Discovers certain actions which reduces anxiety
Develop active avoidance strategies in the form of compulsions
4. Genetic Factors
First-degree relatives are about three to five times more likely to be

affected
Higher concordance rate for monozygotic twins than for dizygotic twins

Increase rate of other disorder among relatives such as generalized

anxiety disorder, body dysmorphic disorder, hypochondriasis, eating


disorder
B. Epidemiologi
1. Prevalence
The lifetime prevalence in general population is 2 3%
2. Age
The mean age of onset is about 20 years
Others have onset before 25 years old or after 35 years old
3. Sex
Among adults, men and women are equally likely to be affected
Men have slightly earlier age of onset
Among adolescent, boys are more commonly affected than girls
4. Course
Chronic with fluctuating or constant pattern
C. Gejala Klinis
Obsessions
Compulsions
Repetitive behavior or mental acts
Recurrent and persistent thoughts,
Individuals feels driven to perform
urges, or images that are
in response to obsession or
experienced
according to rules that must be
At sometime during the
applied rigidly
disturbance, as intrusive and
The behavior or mental acts are
unwanted,
aimed at preventing or reducing
In most individual cause marked
anxiety or distress or preventing
anxiety or distress
dreaded event or situation
The individuals attempts to ignore
These behaviors or mental acts are
or suppress such thoughts or to
not connected in realistic way with
neutralize them with some other
that they are designed to neutralize
thought or action
or prevent, or clearly excessive
Terdapat 4 pola gejala utama pada gangguan obsesif kompulsif, yaitu :
1. Kontaminasi
Obsesi tentang kontaminasi yang diikuti dengan perilaku mencuci,
membersihkan, atau menghindari objek tertentu
2. Sikap Ragu ragu
Obsesi tentang ragu ragu yang diikuti dengan perilaku memeriksa
Biasanya berhubungan dengan situasi berbahaya atau kekerasan seperti
lupa mematikan kompor atau tidak mengunci pintu
3. Pikiran yang Intrusif
Gagasan, pikiran, atau impuls yang menganggu dan berulang, biasanya
tentang seks atau agresif, tetapi tidak disertai kompulsi
4. Simetri
Obsesi yang berhubungan dengan kebutuhan untuk simetri dan ketepatan
sehingga bertindak lambat

Contohnya adalah makan berjam jam atau mencukur kumis dan janggut
D. Terapi
SSRI atau klomipramine
Terapi perilaku