Neurotic & Stress-

related, Somatoform
disorder AND DEPRESSION
 GANGGUAN KECEMASAN (ANXIETY)
Anxiety=cemas =/= Fear = takut
Sering dipakai untuk menyatakan keadaan yang sama
(Interchanges)
Fear = an emotional and physiological response to
recognized external threat
Anxiety = is unpleasant emotional state, the source of
which are less identified
Sering disertai dgn gejala fisiologis (fisik) fatigue,
exhaustion

Variation:
Intensity : minor qualm trembling panic
(extreme)
Course : peak in a few second minutes days
7/19/2017 2
Duration : a few second hours days or months
Dibedakan :
Uncued : Spontaneous anxiety or S.panic (extreme)
Cued : phobic, or situational anxiety ; phobic or
situational panic (extreme)

Anticipatory anxiety (panic) : dicetuskan (triggered) oleh

pikiran dalam kondisi khusus
Normal >< patologis batas tidak jelas
penderita dengan depresi primer anxiety
Anxiety primer depression
7/19/2017 3
TEORI2 KECEMASAN (ANXIETY)
A. Genetic : paling banyak pd first-degree relatives
B. Psychodynamic :
Anxiety : a signal to ego of the emergence of an
unconscious conflict or impulse; indication of
hidden psychological conflict
C. Learned :
Anxiety adlh respon yg dipelajari terhadap situasi atau stimulus
yg dianggap berbahaya
Anxiety menghindar (avoid) dr situasi anxiety berkurang
Unpredictable situation Generalized Anxiety Disorder
(ragu2 kapan akan menghindar) 4
D. Biochemical : compared with normal
Anxiety disorder : heart rate >, blood lactate level >,
oxygen depth moderate exercise .
Panic disorder : > sensitif pd zat2 ttt : caffeine, lactate,
isoproterenol, ephedrine, yohimbine, piperoxane
(peningkatan aktifitas locus ceroleus)
Benzodiazepine sifat sama dengan GABA ( inhibitory
neurotransmitter)
Abnormal serotonin Obsessive-Compulsive Disorder
(SSRI sebagai obat OCD)
7/19/2017 5
 EPIDEMIOLOGI
National Institute of Mental Health Epidemic
Catchment Area (NIMH-ECA) study (Meyer et, al,
1984) : prevalensi 6 bulan =8,3% ( 23% mendapat
pengobatan)
National Comorbidity Survey (Kessler et.al,1994)
The lifetime prevalent of anxiety = 24,9%

7/19/2017 6
ICD 10 1992
F40 Phobic Anxiety Disorder
F40.0 Agoraphobia
F40.00 without panic disorder
F40.01 with panic disorder
F40.1 Social Phobia
F40.2 Specific (isolated) phobia
F40.8 Other phobic anxiety disorder
F40.9 Phobic anxiety disorder, unspecified
F41 Other anxiety disorder
F41.0 Panic disorder (episodic paroxysmal anxiety)
F41.1 Generalized anxiety disorder
F41.2 Mixed anxiety and depressive disorder
F41.3 Other mixed anxiety disorder
F41.8 Other specified anxiety disorder
F41.9 Anxiety Disorder, unspecified
F42 Obsessive-Compulsive Disorder
F42.0 Predominantly obsessional thought or rumination
F42.1 Predominantly compulsive acts (obsessional rituals)
F42.2 Mixed obsessional thoughts and acts
F42.8 Other Obsessive-Compulsive disorder 7
F42.9 Obsessive-compulsive, unspecified
F43 Reaction to severe stress and adjustment disorder
F43.0 Acute stress reaction
F43.1 Post-traumatic stress disorder
F43.2 Adjustment disorder
.20 Brief depressive reaction
.21 prolonged depressive reaction
.22 mixed anxiety and depressive rection
.23 with predominant disturbance of other emotion
.24 with predominant disturbance of conduct
.25 with mixed disturbance of emotion and conduct
.28 with other specified predominance symptoms
F43.8 Other reaction to severe stress
F43.9 Reaction to severe stress, unspecified

7/19/2017 8
F44 Dissociative (conversion) disorder
F44.0 Dissociative amnesia
F44.1 Dissociative fugue
F44.2 Dissociative stupor
F44.3 Trance and possession disorder
F44.4 Dissociative motor disorder
F44.5 Dissociative convulsion
F44.6 Dissociative anesthesia and sensory loss
F44.7 Mixed dissociative (conversion) disorder
F44.8 Other dissociative (conversion) disorder
.80 Genser Syndrome
.81 Multiple personality disorder
.82 Transient dissociative (conversion) disorder occurring in childhood and
adolescence
.88 Other specified dissociative (conversion) disorder
F44.9 Dissociative (conversion) disorder, unspecified
7/19/2017 9
F45 Somatoform disorder
F45.0 Somatization disorder
F45.1 Undifferentiated somatoform disorder
F45.2 Hypochondriacal disorder
F45.3 Somatoform autonomic dysfunction
.30 Heart and cardiovascular system
.31 Upper Gastrointestinal tract
.32 Lower Gastrointestinal tract
.33 Respiratory system
.34 Genitourinary system
.38 Other organ or system
F45.4 Persistent somatoform pain disorder
F45.8 Other somatoform disorder
F45.9 Somatoform disorder, unspecified

F48 Other neurotic disorder

F48.0 Neurasthenia
F48.1 Depersonalization-derealization syndrome
F48.8 Other specified neurotic disorder
F48.9 Neurotic disorder, unspecified
7/19/2017 10
 GANGGUAN PANIK (PANIC
DISORDER)
Panic attacks >> panic disorder
Serangan panik (Panic attacks) : 35% of
population experience panic attacks in the
course of life
* Symptoms and signs :
Panic attacks : is not codable. (mis: agoraphobia
dgn panik)
-Mulainya mendadak 10 -30 minutes
-Sulit membedakan panik dengan
anticipatory anxiety 11
7/19/2017
Episode mendadak tak dapat dikendalikan (disteering)
Perubahan fungsi fisiologik
Fears of death, going crazy, doing something uncontrolled
Disertai 3-9 of the 13 symptoms :
1. Palpitation, pounding heart, or accelerated HR
2. Sweating
3. Trembling or shaking
4. Sensation of shortness of breath or smothering
5. Feeling of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feeling dizzy, unsteady, light headed, or faint
9. Derealization (feeling unreality) or depersonalization (spt terpisah dr dirinya)
10. Fear of losing control or going crazy
11. Fear of dying
12. Paresthesia (numbness or tingling sensation) 12
13. Chills or hot flashes
DSM IV criteria for panic disorder without agoraphobia:
Both (1) and (2)
A. Recurrent unexpected panic attacks
(1) At least one of the attacks has been followed by 1 month
(more) of one (more) of the following
(2) Persistent concern about having additional attacks
a. Worry about the implication of the attacks or its
consequences (eg. Losing control, having heart attacks,
going crazy)
b. A significant changes in behavior related to the attacks
B. Absence of agoraphobia
C. The panic attacks are not due to the direct physiological effect
of a substance (eg. Drug abuse, a medication)
D. The panic attacks are not better accounted for by another
Mental disorder
DSM IV Panic disorder with agoraphobia
A
B. Presence of agoraphobia
C..
7/19/2017 D 13
Differential diagnosis:

- Somatic condition:
Angina pectoris, acute myocardial infarction, arrythmia, congestive
heart failure, shock. Asthma, emphysema, pulmonary embolism,
encephalopathy, seizure disorder, tumor, vertigo, anemia,
anaphylactic shock, diabetes, hypo/hyperthyroidism, parathyroid,
cushings disease, phaeochromocytoma.

medication :
antispasmodic, cold medicines, digitalis, stimulant
Paradoxically anti anxiety and antidepressant
7/19/2017 14
Epidemiology :
NIMH-ECA : 6 month prevalence =0,7 %
National comorbidity survey = 2,3 %
1/3 orang-orang mengalami episode tunggal dari ggn. panik per
tahun

Etiology and pathogenesis

*Patofisiologi yg mendasari belum jelas
*Diyakini mempunyai dasar biochemical
Suspect:
- Noradrenergic dysfunction mediated through the locus ceroleus
- Mungkin berhubungan dgn early separation anxiety (school
avoidance) agoraphobia 15
TREATMENT :
Empirical : faktor etiologi belum jelas
A. Psychological treatment :
ada hasil positif dgn psychotherapy. Tidak ada jenis
psychotherapy ttt yg paling efektif. Kemajuan : lewat
relasi dokter-pasien yg baik :
Mis: harapan2 berhasil, percaya pd terapi, reassurance,
encouragement, empathy
Cognitive therapy:
Reassignment of the physiological component of panic
from life threatening to familiar and manageable :
-attempts to modify catastrophic negative thought
-attempts to help patient familiar with the symptoms
symptoms is unpleasant but not dangerous
attack will end soon 16
B. Behavioral Therapy
Exposure therapy (desensitisasi)
-Agoraphobia with spontaneous panic attacks (frequency and severity <<
with medication)
-Panic only without anticipatory anxiety/avoidance can exposed, in
imagination
-The treatment of choice for panic attacks accompanied by anticipatory
anxiety and avoidance
Relaxation therapy
C. Drug therapy
-Antidepressant : tricyclic, SSRI
-Benzodiazepine gol. alprazolam and clonazepam (reaksi lbh cepat, risiko
ketergantungan)
- adrenergic blocking agent eg. Propanolol
-Kombinasi medikasi dan terapi kognitif-perilaku / CBT (angka relaps <<
mengikuti pengurangan terapi obat2an)
7/19/2017 17
 AGORAPHOBIA
* Fear of being caught in situation from which a graceful
and speedy escape to safety would be difficult or
embarrassing if patient felt discomfort (panic) ,
eg: -Attendance at auditorium
-Shopping in supermarket
-Using public transportation
-Driving under condition in which opportunities to pull
over, stop, or get off the highway quickly maybe
restricted
-Eating out 18
Differential diagnosis :
Gejala avoidance dan withdrawal juga ada pada :
-Depresi, schizophrenia, paranoid disorder,
some organic mental disorder
-Other anxiety disorder (eg, social/ specific
phobia, OCD and PTSD)

Prognosis
-Mungkin bisa remisi spontan
-Untreated chronic (exacerbation-remission)
incapacitated with anticipatory anxiety and
avoidance
-Abuse alcohol and other substance
19
-Perubahan peran dalam keluarga
Epidemiology

NIMH-ECA : 6 month prevalence : 3,8 % in females, 1,8% in

males
Usia onset : 20 tahunan, > 40 thn (uncommon)

Etiology and pathogenesis :

-mungkin faktor keturunan
-Panic agoraphobia panic

7/19/2017 20
TREATMENT :
A. Psychological
-No specific psychotherapies
-Semua terapi termasuk medikasi dan perilaku(behavioral)
harus mengandung edukasi dan support
B. Behavior therapy
Exposure therapy : paling efektif, petunjuk sederhana
C. Drug treatment :
Panic (+) drug treatment (+)
Panic (-) drug treatment (-) exposure therapy
7/19/2017 21
 SOCIAL PHOBIA
(= Social anxiety Disorder)

Symptoms and sign

ketakutan yg persisten dan disadari irrational pada situasi sosial,
performance mereka akan memalukan atau mdpt penghinaan
Individu normal : anxiety enhance performance
social phobia : anxiety performance

Social phobia :
Spesifik (mis: public speaking)
General (pd banyak aspek social)
Bentuk ekstrem avoidance personality disorder 22
DD:
ciri2 ansietas and avoidance social situation terdapat pula pada :
schizophrenia, MDD, OCD, paranoid dan avoidance personality
disorder

Prognosis
Mild , jarang, mengganggu fungsi penderita
More severe, mengganggu fungsi dan sangat menderita
Berganti pekerjaan/profesi
General social phobia low income

7/19/2017 23
Epidemiology
Banyak penderita social phobia semasa kecil pemalu
Tapi banyak anak kecil pemalu tidak berkembang mjd social phobia
Usia onset : 20 th, jarang: 30 th
NCS : prevalensi : male = 6,6%, female 9,1 %
Most severe cases pria >>

Etiology and pathogenesis

Penyebab spesifik (-)
Family history (+) keturunan atau environtment ????

7/19/2017 24
 Treatment :
A. Psychotherapy
efektifitas belum teruji
B. Behavioral therapy
Exposure therapy :
- dgn videotape feedback/ fantasy (ketakutan public speaking)
- Paradoxical exaggeration ( mengulang2 hal2 fear)
C. Drug treatment
adrenergic bocker peripheral symptoms (tremor, tachycardia,
sweating)
Benzodiazepine kombinasi dengan beta blocker
Gabapentin (tidak menyebabkan dependensi)
MAOI (phenelzine, RIMA) hati2 adanya tyramine
25
SSRI (first line), mis: paroxetine
 SPECIFIC PHOBIA

Kurang berat daripada phobia lainnya

Paling umum fobia pada obyek atau situasi :
Snake, spider, insect, blood injury, heights, elevators, small
closed spaces and flying
Insect phobia didalam rumah terus

Flying phobia masalah pd saat traveling

Blood injury nasovagal syncope

Menghindari mengunjungi dokter/dokter gigi

7/19/2017 26
Epidemiology, etiology, pathogenesis and treatment

Paling umum dari anxiety disorder

Puncak onset waktu kanak2 (orang asing, binatang besar,
ular, tempat gelap dan luka2)
The NIMH-ECA = 7% in females, 4,3 % in males
National comorbidity survey : 12 month prevalence : 13,2%
in females, 4,4 % in males
Treatment : exposure therapy (desensitisasi)

7/19/2017 27
OBSESSIVE-COMPULSIVE DISORDER

Symptoms and signs

Obsessions : repetitive, intrusive ideas, images or impulses
Fokus pada : charming other, acquiring or spreading
contamination, losing things, doubt about having performed
routine task properly, dan melampaui norma sosial (mis:
melakukan aktifitas seksual yg tak bisa diterima norma)
Compulsive rituals : repetitive thoughts or acts performed to
decrease anxiety and other discomfort
Misal: cleaning, repeating, checking, tidying, hoarding and
avoiding (hampir tiap waktu saat terjaga)
7/19/2017 28
DD:
Secondary complication of major disorder
Obsesi saja = depresi atau schizophrenia
Phobia : lebih takut thdp obyek yg ditakuti, kurang kompleks,
lebih khusus (misal: takut pingsan sementara tekanan darah
menurun)
Ansietas pada fobia lebih hebat dari OCD

Prognosis
Disfungsi (mengendalikan obsesi dan rituals)
Usually last decades
Memburuk bila penderita depresif
Mereda sejenak dan digantikan bentuk OCD yg baru
29
Mengganggu fungsi keluarga
Epidemiology
1/3 of OCD onset at the age 15
Men < women
NIMH-ECA : 6 month prevalence 1,5%
Lifetime prevalence 2,5%

Etiology and pathogenesis

OCD clusters dalam keluarga sebagian herediter
Kesan : dysfunction of serotonin neurotransmission
In circuit involving the orbital cortex
Caudate, globus pallidus and thalamus
7/19/2017 30
Treatment :
A. Behavioral therapy
-Exposure and prevention ritualistic: (menghasilkan 60-80 penurunan gejala
pada pasien2) Who are able to comply with treatment instruction
-anggota keluarga membantu terapi (co-therapists)
-banyak OCD mjd reassurance junkies (reassurance dipandang sbg ritual
utk menghindari ansietas)
B. Drug therapy
Anti depressant : clomipramin, SSRI (flouxetine, fluvoxamine, paroxetine
and sertraline), citalopram
Anxiolytics : peran terbatas, kadang2 membantu mengatasi ansietas akut
Antipsychotics : standard antipsychotics ditambahkan pd SSRI, atypical
antipsychotic (augmentation)
C. Other treatment
ECT : mengatasi OCD dgn depresi primer
Psychotherapy : masih dipakai, perbaikan tidak jelas
Neurosurgery : anterior cingulotomy, stereotactic limbic leucotomy, anterior31
capsulotomy
 SOMATOFORM and
DISSOCIATIVE DISORDER
Historically
Linked together
Dianggap manifestasi berbeda
Psychological process serupa
Traumatic experiences :
domestic violence
sexual abuse symptom ada pd individu yg sama;
berturut-turut atau bersamaan
7/19/2017 32
SOMATOFORM
Gejala seperti gangguan somatik
No physical and laboratory finding
Anggapan = sumber dari masalah psikologis

Survey reports :
60-80% general population will suffer somatic
symptoms/week
60% visitor to physician have no physical/ biological diff
20-30% these px with significant psychological aspect 33
 Subtype of somatoform:

1. Body dysmorphic disorder

2. Somatization disorder
3. Conversion disorder
4. Somatoform pain disorder
5. Hypochondriasis

7/19/2017 34
BODY DYSMORPHIC DISORDER
concern about their body
Recent research : as part of OCD spectrum
2% (?) in general population
Preoccupation : membayangkan penampilan yg kurang. Bila ada
sedikit cacat concern >>
Focus concern : kerutan atau noda pd kulit, rambut wajah, bentuk
hidung, mulut, rahang, dll
Sadar bahwa konsern berlebihan delusional intensity
Khas: mencari reassurance mengenai kondisinya tapi jarang mereda
Banyak penderita severely impaired dan tak mampu berfungsi
Sering mdpt perawatan RS dan depresi (suicide attempts)
Intervention/ reconstructive or plastic surgery tidak meredakan
preokupasi penderita
Treatment: anti OCD: clomipramine, fluvoxamine 35
SOMATIZATION DISORDER
Historically : hysteria and Briquets syndrome
Symptoms and signs :
Multiple physical symptoms
Over a period of several years
Tidak berhubungan dgn penyakit fisik dan tak ada bukti yg
mendukung adanya penyakit fisik
Shopping doctor (Seen many physicians simultaneously)
Sering berkaitan dgn : depression, anxiety
Sering bersamaan dgn gangguan dissociative dan PTSD, juga
histrionic dan antisocial personality disorder
Sering bersamaan dgn adanya kesulitan pekerjaan, interpersonal
dan masalah perkawinan
Keluhan paling sering ; nyeri, gejala psikoseksual, gejala yg
berkaitan dgn neurologik, GI dan sistem reproduksi 36
RIWAYAT UMUM:
Sering mulai usia remaja, sebelum 30 th, pada wanita masalah
menstruasi sebagai onset
Chronic, fluctuative
Remisi spontan jarang terjadi
Symptom be quite severe ketidakmampuan yg mengganggu
pekerjaan dan relasi interpersonal
Ganti2 dokter iatrogenic complication, substance abuse, dan
suicide attempts
Unnecessary health care biaya tinggi

7/19/2017 37
DD:
multiple sclerosis, SLE, hyper parathyroid, porphyria, schizophrenia
with multiple somatic delusion, MDD with somatic symptom, panic
disorder, PTSD, conversion disorder, factitious disorder

Prognosis :
Tanpa treatment buruk
Lifelong pattern of seeking medical attention iatrogenic
complication

Epidemiology
Lifetime prevalence 1,5% -3,5%
Families : alcohol abuse, antisocial personality, ADHD
Banyak pd domestic violence : mis. sexual abuse
7/19/2017 38
Etilogy and pathogenesis
Strong relationship with traumatic experiences, dissociation, affect
dyregulation
Pathological identification to ill parent
Treatment
Chronic px sukar untuk di refer ke psikiater
They regard as physically rather than mentally ill
Its not nothing is wrong they are psychiatrically ill
The positive way :
I am happy to tell you that the findings are normal.
I am reassure you that no life threatening condition.
That means we are can proceed carefully and slowly to work with you on your difficulties.
I am sure you dont want all kind of test or procedures with all those potential side effect and complication

Therapy :
Cognitive Behavioral therapy
Psychotherapeutic
Pharmacological approaches
CONVERSION DISORDER
= hysterical neurosis, converse type
Symtoms and signs :
Characterized : hilangnya/ perubahan fungsi fisik
Kesan: seperi gangguan fisik
Sbg pengganti ekspresi konflik psikologik atau kebutuhan yg tak
terpenuhi
Tidak disengaja/disadari (The symptom is not under voluntary)
Tidak dapat dijelaskan scr jelas spt ggn. fisik
Gejala konversi :
-Suggesting neurological disorder : paresis, paralysis, aphonia,
seizures, blindness, anesthesia
-Autonomic nervous system : vomiting
-Endocrine system : pseudocyesis 40
RIWAYAT UMUM:
Konversi mulai saat usia berapa saja, terbanyak usia remaja
Bisa hanya sekali saja, tapi bisa berulang-ulang
Onset sering tiba-tiba dan dalam konteks terdapat stres psikologik
Durasi umumnya pendek, resolusi cepat
May develop chronic CD with loss of function persisting for years
Patient with apparent conversion symptom
Have clear-cut medical illnesses
Caused the supposed conversion symptom or significant psychiatric pathology such as
depression or psychosis
Patients with chronic neurological disorder (epilepsy)
Develop symptom (eg, pseudo epileptic fits) without physical evidence of
active disease
Patients learned the conversion symptom
Symptom of conversion disorder
At risk for cost and complication or unnecessary medical or surgical
treatment
7/19/2017 Actual physical problem, contracture disease atrophy 41
PredisposIsi :
Somatic disorder, psychological distress. Histrionic and dependent personality
Histories of trauma, abuse and dissociation
DD : somatic disease : multiple sclerosis
Somatization disorder, DID, hypochondriasis

Prognosa :
Dapat sembuh tanpa pengobatan
Dapat bertahan bertahun-tahun

Epidemiology
More common in 19th century
Women >>
Today appears in patients seen in nonpsychiatric
DSM IV report rate 10-300 / 100.000 (in general population)
7/19/2017 42
Etiology and pathogenesis :
Psychoanalytic : dorongan sexual atau agressivitas yang tidak bisa diterima
(moral) dengan mekanisme represi di bawa ke alam bwh sadar (denied)
energy mental (urge) didorong ke conscious experience (tidak disadari)
symptom somatic (symbolic expression=protection)

19th century mulai perhatian kalangan medis terhadap conversion symptom

dikenal nama2:
Paul Briquet : kesengsaraan, kehilangan dan kejadian traumatik
Jean-Martin Charcot : a degeneration of nervous system
Pierre Janet : Selected mental content could be removed from
consciousness but could continue to produce motor and sensory effects
Etiology dissociative and hysterical = traumatic experiences
Freud : Emotions associated with traumatic event were morally
unacceptable to woman repressed unconscious. The mental energy
associated with these emotion denying converted into somatic
symptoms 43
TREATMENT :
Freud and Janet developed psychological paradigm for treatment
patient with conversion :
Emphasized verbalization of traumatic experience and or
psychological conflict
Transformation of the meaning of the symptoms to help patient
master the traumatic event
In World war II :
Narcosynthesis = Amytal interview trance like (relaxed state) +
psychotherapy encourage to remember traumatic event and
emotion associated with the onset of conversion relieving accepted
and remembered symptom (-)
In General hospital setting :
Acute conversion treated with some combination :
Psychotherapy, hypnotherapy, and or narcosynthesis
Long term psychotherapy and or psychopharmacological intervention 44
indicated to treat PTSD and mood disorder comorbid with conversion
SOMATOFORM PAIN DISORDER
Major complaint : preoccupation with pain > 6 month, no explanatory
physical findings, psychological factor not necessary. Lihat DSM IV
RIWAYAT UMUM
shopping doctor dx/ and relief pain risiko substance abuse
Complain anxiety atau depression tidak menonjol
Mulai pada remaja dan dewasa muda
Onset mendadak dan meningkat keparahannya dalam bbrapa hari
ke minggu
Bisa reda scr spontan atau dgn pengobatan
Bisa mjd kronis meskipun diobati
Severe symptom bisa mengganggu fungsi keseluruhan iatrogenic
complication of medical or surgical treatment
7/19/2017 45
DD :
Painful physical disorder : atherosclerotic coronary artery, Lumbar
disk disease
Dramatic presentation of physical pain out of proportion to physical
finding (manner of expressing pain personality)
Also placebo effect of medication / suggestion
Pain in somatization, conversion, major depression and
schizophrenia (not dominate the clinical picture)
Malingering and factitious disorder (pain under control)

Prognosis :
Prognosis buruk
Clinical experience : better prognosis : continue to participate in
regularly schedule activities, and who do not allow the pain became
46
the dominant aspect of their life
Epidemiology
Prevalent of somatoform pain disorder is not known yet
Women > men
Familiar distribution (-)
Depression and alcohol abuse may be common in families
History of childhood sexual abuse in : chronic pelvic pain,
fibromyalgia, refractory headaches and chronic back pain.

Treatment :
Pendekatan multidisipliner (neurologis, internis, anesthesiologist, an
addition to psychiatrist) dlm penanganan nyerinya. Meskipun
hubungan antara nyeri dan depresi belum jelas, dengan pemberian
anti depressant nyeri dapat membaik
Specialist treatment resources (-), menggalang suport sosial to
prevent unnecessary medical and surgical procedures. 47
 HYPOCHONDRIASIS
Dahulu = hypochondriacal neurosis

Symptoms and signs :

Keluhan:
Masalah fisik ringan
Kekhawatiran tdk realistis mengenai penyakit serius
Selalu mencari penanganan dokter (professional care)
Mengkonsumsi berbagai obat2 yg kerap berlawanan
Mengganggu fungsi sosial dan pekerjaan
Mengartikan fungsi normal/gangguan ringan sebagai bukti adanya penyakit
serius
Ketakutan umumnya mengenai berbagai sistem organ
Bisa juga sistem organ tunggal. Misal: Cardiac Neurosis
7/19/2017 48
Riwayat umum :
Biasanya berhubungan dgn kecemasan, depresi dan ciri kepribadian compulsif
Bila ditanya tentang kesehatannya, responnya:
Keluhan sangat lama
Tampak frustrasi pada dokternya dan inadequate medical care
Mulai saat remaja, tapi mgkn tidak muncul smp usia 40 th pada pria, 50 pd
perempuan
Kronis, meskipun berfluktuasi
Mengganggu fungsi sosial dan pekerjaan (misal: berbaring di tempat tidur,
menggunakan life-style orang sakit)
Cenderung mencari penanganan dari beberapa dokter yg berbeda (shopping
doctor) berisiko mendapat penanganan atau operasi yg tidak perlu biaya
dan komplikasi >>

DD :
Actual serious somatic disease
Somatic delusion from schizophrenia or major depression
49
Somatization (multiple physical symptoms)
Prognosis : Kronis prognosis buruk

Epidemiologi
Banyak dijumpai di praktek dokter umum
Frekuensi men = women

Etiologi dan pathogenesis :

Believed have maladaptive with unmet psychological needs or unconscious
psychological conflict
Specific psychological mechanism ???
Excessive self concern
Menggambarkan ekspresi fisik dari low self-esteem
Melindungi individu dari kesadaran mengenai impuls2 destruktif
Kesukaran mengatakan atau mengekspresikan emosi physical symptom
(childhood abuse or neglect)
7/19/2017 50
Treatment :

Psychotherapy bermanfaat hanya pd beberapa pasien

Tidak ada pengobatan somatik yg efektif
Dokter (umum) harus menghentikan upaya untuk memberi
pengobatan yg hanya mengurangi gejala:
Memahami kekhawatiran dan keluhan2 pasien
Mengenali bahwa gejala2 adalah chronic psychiatric disorder
Group therapy

7/19/2017 51
DEPRESSION DISORDER
(Gangguan depresi)

Depresi: sebagai gangguan (disorder)

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(bete/perasaan tertekan) ?
Depression is common: all ages, cultures
and backgrounds
Th 2020: the most global disease burden
in the world! Quality of Life
PENYEBAB
Faktor biologik :- Genetik
- neurotransmitter
(terutama serotonin)
Faktor kognitif (distorsi kognitif):
- distorted automatic thoughts
- maladaptive assumptions
- negative schemas
Faktor risiko:
- unhappy experiences in childhood
- difficulties in relationships, occupational,
marital conflict, etc
- loss of love object
EPIDEMIOLOGI
Lifetime prevalence: 6%
At some stage in their life, about 1 in 5-7 people will
experience at least a short period of depression
Onset sebelum 25 th (50% Px)
Women 2-3x than men: (hormonal influences)
- premenstrual dysphoric disorder
- depression related to hormonal
contraception
- abortion and miscarriage and
depression
- pregnancy and depression
- postnatal depression
- infertility and depression in women
- perimenopause, menopause and depression
Symptoms:
Feeling down/blue all day
Gangguan tidur ( insomnia or sleeping too much)
Oversensitive (irritable)
Sulit konsentrasi / sulit mengambil keputusan
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Merasa tidak berharga (self-esteem )
Cepat lelah
Kehilangan semangat
Kehilangan interest (anhedonia)
Perubahan nafsu makan (makan terus atau kehilangan
nafsu makan) perubahan BB
Gelisah (restlessness) atau lamban (slowness)
Tidak berdaya
Putus asa
Pikiran tentang kematian (suicide)
Course and prognosis

20% berkembang mjd depresi major

20% berkembang mjd bipolar disorder
>25% mjd kronis

Terapi
Medikasi antidepresan: tricyclic antidepresant,
SSRI (serotonin selective reuptake inhibitors)
Psikoterapi
Cognitive Behavior Therapy (CBT)