(J) Psychological and Physiological of a Head Down Titled Condition

7/26/2019 (J) Psychological and Physiological of a Head Down Titled Condition

1/39

DELHI PSYCHIATRY JOURNAL Vol. 14 No.1

APRIL 2011

Newer DevelopmentDelhi Psychiatry Journal 2011; 14:(1) Delhi Psychiatric Society

138

The Psychiatric and DentalInterrelationshipBharti Tomar*, Navneet Kaur Bhatia**, Pankaj Kumar***, M.S. Bhatia***, Rupal J. Shah*

*Government Dental College and Hospital, Ahmedabad

**Santosh Dental College and Hospital, Ghaziabad

***UCMS, GTB Hospital, Dilshad Garden, Delhi-110095

Oral health is an integral part of general

health.There is evidence that patients suffering from

mental illness are more vulnerable to dental neglect

and poor oral health1. Sims reported that physical

health problems are more common in psychiatric

patients2. They seem to be poorly recognized by

psychiatrists, and oral health is no exception.

Psychiatric disorders affect the general behaviour

of a person, impair level of functioning and alter

perception towards oral health. Eating and sleeping

patterns take precedence over personnel hygiene,

making them susceptible to many oral diseases.

Alternatively, oral symptoms may be the first

or only manifestation of a mental health problem

e.g., facial pain, preoccupation with dentures,

excessive palatal erosion or self- inflicted injury.The two diseases which have a major impact on

the oral cavity are dental caries (tooth decay) and

periodontal disease (gum disease).Dentists spend

a considerable amount of time treating patients who

present with either psychiatric disorders like

depression and anxiety or with physical manifesta-

tions of underlying emotional disturbances.

Common manifestations of covert emotional

disturbance in patients in dental practice include

oral dysaesthesia, atypical facial pain and other

atypical syndromes3. Increasing attention needs to

be given to identify and appropriately treatsomatoform disorders, more so, as they constitute

one-third to one-half of referrals to any liaison

psychiatry service4.

Somatoform disorders, apart from posing

management problems, also cause significant

functional impairment and overall disability for the

patient5. Bass et al6 recognized somatoform

disorders as severe psychiatric disorders and

suggested that they be treated by psychiatrists or

psychologists.

Recognizable psychopathology is seen in up

to 30% of patients attending dental clinics7 and thisoften goes undetected and hence untreated. Dental


2/39

specialists, often come across patients, who present

with complaints of pain, abnormalities of sensation,

movement and salivation involving the mouth and

face, which are a manifestation of underlying

emotional disturbance and not due to a clearly

identifiable physical cause. Early and appropriate

recognition of such emotional distress would benefit

both the individual and the health service8.

Given the prevalence and impact of

unrecognized and untreated psychiatric disorders

in patients presenting in dental practice, there

follows the need for a service to address this unmet

need. This would directly provide a framework for

psychiatric- dental liaison and indirectly lead to

better understanding of psychiatric disorders by

dental specialists, which in turn will lead to early

identification and referral to such a service if one

exists. It has been shown elsewhere9 that availabilityof psychiatric liaison service will lead to an increase

in rate of referrals.

Types of Major Dental Conditions

Recognition of a dental problem does not mean

that the appropriate action will be taken. As an aid

to decision-making, the following section provides

a brief overview of the main oral diseases and

conditions

Dental caries

Dental caries is the disease process which

destroys the hard layers of teeth. It is the result of

the demineralization of enamel and dentine byacidsproduced as by-products of the metabolism of

fermentable carbohydrates by dental plaque

microorganisms. This results in cavitation of

specific sites on the tooth surface and as a

Page 2APRIL 2011

DELHI PSYCHIATRY JOURNAL Vol. 14 No.1Delhi Psychiatry Journal 2011; 14:(1) Delhi Psychiatric Society

139

consequence produces pain and unsightly teeth.

Good oral hygiene alone is normally insufficient toprevent tooth decay. Treatment of dental caries,

once it has produced a cavity, involves either the

restoration or extraction of affected teeth. The

incidence of missing teeth is higher (38.57%)

among study group and 37.79% in controls10(is in

agreement with other studies11,12., indicating there

is rapid progress of caries to a point where

extraction becomes necessary.

Periodontal disease

Periodontal disease only occurs in the presence

of dental plaque. Initially the disease causes

inflammation ofthe gingivae and at this stage theprocess is reversible. If it progresses to destroy the


3/39

periodontal tissue (periodontitis), this is

irreversible. If allowed to progress unchecked,

periodontitis will result in tooth loss. Preventive

strategies mainly involve reducing dental plaque

levels by improved oral hygiene techniques. As the

initial stages of the disease are reversible, early

intervention to improve oral hygiene gives the

greatest benefit. Drug induced overgrowths of

gingivae are common due to pharmacologic

drugs(antiepileptics like phenytoin), which creates

favourable condition for retention of plaque,

creating a vicious circle which enhances the

gingival inflammation and ultimately loss of tooth

if unrecognized and untreated.

Oral cancer

The prevalence of oral cancer increases with

age and 98% of cases occur over the age of 40 years.

The major causes of oral cancer are smoking,chewing tobacco and alcohol consumption.

Addressing these aspects are the basis of a

preventive strategy. The detection of pre-cancerous

lesions in the mouth brings major benefits. It

improves the survival rate and reduces the distress

associated with some forms of radical surgery or

radiotherapy. Cancer of the head and neck affects

the psyche as well as the soma and , as such calls

for a comprehensive approach to treatment.

Psychiatrists and dentists should be aware that

patients normally react to the phenomenon of cancer

as a grievous event and experience emotions suchas denial, depression, anxiety, guilt and fear.

Locating in the highly visible area and personally

identifying place, head and neck cancer has serious

social consequences and evokes symbolic sexual

conflicts.

Tooth wear

Tooth wear tends to increase with age. It may

be caused by attrition (which is the action of one

toothgrinding upon another), abrasion (where the

tooth surface is worn by another agent, for example,

a toothbrush) or erosion in which there is chemical

dissolution of the tooth. A major factor in the

erosion of tooth enamel and dentine is an

excessively acidic diet, notably citrus fruits and

carbonated drinks. Some studies have recorded over

40% of some tooth surfaces affected by erosion

associated with dietary acids13. Attention to diet is

the main focus for the prevention of tooth erosion.

The clinical features of anorexia nervosa includes

a pattern of enamel dissolution in cases of vomiting,

regurgitation, and/or the consumption of large

amounts of citrus fruits; and an altered caries

response due to abnormal carbohydrate consump-tion. Despite the patients probably insistent denial

of anorectic eating habits, dentist should consider


4/39

the existence of anorexia nervosa in the presence

of such abnormal features, especially in young

women.Whereas the somatic changes occurring

with anorexia nervosa are reversible, those affecting

the hard dental tissues are not.

The term perimolysis is used by Hoist and

Lange14 to describe the destruction of tooth tissue

due to persistent vomiting. Cases of dental damage

resulting from regurgitation or vomiting as

symptoms of such medical conditions as hiatus

hernia, gastric dysfunction, duodenal or peptic

ulcer, antabuse therapy for alcoholism, and during

pregnancy are well documented.

Xerostomia, Sialorrhoea and other Disorders

Saliva plays an important role in oral health. It

contains glycoproteins and mucoproteins which

lubricate the oral cavity and enhance food bolus

formation, translocation of food and initiation ofswallowing. It also contains peroxidases and

lysozymes which have antibacterial properties.

Saliva buffers and neutralizes acids produced by

bacteria from foods. Saliva also facilitates the

articulation of speech. Xerostomia (reduced

salivary flow) has been implicated in a range of

Page 3DELHI PSYCHIATRY JOURNAL Vol. 14 No.1

APRIL 2011Delhi Psychiatry Journal 2011; 14:(1) Delhi Psychiatric Society

dental conditions. Stiefel et al found increased

plaque, calculus formation, caries, gingivitis and

soft tissue lesions in people with reduced salivary

flow. Individuals with xerostomia were also found

to be at greater risk of root and coronal caries

formation14.The effect was increased when multiple

types of medication with xerostomic side-effects

were taken. Xerostomia also predisposes to oral

candidiasis, especially in denture wearers.

Xerostomia can be induced by medication with

anticholinergic sideeffects bytricyclic antidepress-

ants, other antidepressants (e.g. selective serotonin

reuptake inhibitors), lithium carbonate, butyro-phenones, Phenothiazines, Sedatives (including

benzodiazepines), antihistamines, antihypertensi-

ves, anticholinergic drugs, diuretics15etc. Some

autoimmune diseases, for example Sjogrens

syndrome, and exposure to oral radiation may cause

severe xerostomia. Sialorrhoea, which is the over-

production of saliva, is both unpleasant for the

patient and for others, leading to drooling and

soreness of the face. Sialorrhoea is a well-known

side-effect of clozapineand may improve after

reduction in the dose. If clozapine has to be

continued, it is possible to treat the sialorrhoea usinganticholinergic medication.


5/39

In addition to Xerostomia and Sialorrhoea,

medication can produce a variety of other side-

effectsrelevant to dentistry e.g.Abnormal facial

movements, Tics, Grimacing, Oro-facial dyskinesia,

Parkinsonian side-effects, Gingival hyperplasia.

Psychiatric disorders affecting dental health

Dental anxiety

In the general population, psychological

problems relating to receiving dental treatment are

wide spread. It has been reported that about half of

all dental patients experience some anxiety towards

their dental visits16. It is important to recognize the

role that dental fear plays, as it can lead to delay in

seeking necessarydental treatment, cancellation of

appointments and poor cooperation in the dental

chair. Dental fear is one of the most troublesome

patient management problems for the dental team,

causes distress for thepatient and results in highstress levels in dentists.

Dental phobia

Dental phobia is classified in DSM-IV

(American Psychiatric Association, 1994) as a

specific phobia,which involves a marked and

persistent fear of a specific object, activity or

situation that results in anxiety on confronting the

phobic stimulus. Dental phobia is classified as a

specific (isolated) phobiain ICD-10 (World Health

Organization, 1992). People with dental phobia

usually report two types of experiences; a painful

or traumatic dental procedure or negative personalinteraction with dental staff, often in childhood or

adolescence. There may also be fearful attitudes

learned from parents and others, a feeling of lack

of control in the dental situation and the presence

of general anxiety disorders16.

Dental practitioners may treat dental phobia

themselves or enlist the help of the patients general

practitioner or a psychiatrist. It is very important

for the dentist to understand the patients fears and

to explain the nature of the proposed dental

treatment. It has been reported that people with

specific fears such as gagging and needle phobia

respond best to graded exposure in vivo and may

also find relaxation techniques enable them to

accept treatment. Relapse rates were found to be

better in those who had about four hours of therapy.

Those with non-specific fear tend to remain vigilant

and respond less well to behavioural techniques.

Some dental practitioners offer patients a

mixture of nitrous oxide and oxygen to inhale

(conscious sedation), which produces analgesia and

relaxation. Intravenous diazepam can be used for

tranquillization, and music, together with otherdistraction techniques, may help others. Relatively


6/39

few patients will require specialist care. Those with

severe symptoms should have a thorough

assessment by an experienced psychologist or

psychiatrist and a carefully structured treatment

programme. Dental anxiety may, of course, be part

of another type of anxiety disorder.

Generalized anxiety disorder, panic disorder or

agoraphobia may also present with some features

of dental anxiety17. Moore et al18 describe

embarrassment and fear with avoidance, which is

similar to social phobia.

Psychosis

In a Danish study of hospital patients with

schizophrenia, the dental attendance was half that

of the normal population19. Tooth brushing was

down by a third, indicating poorer dental health140

Page 4APRIL 2011

DELHI PSYCHIATRY JOURNAL Vol. 14 No.1Delhi Psychiatry Journal 2011; 14:(1) Delhi Psychiatric Society

141

behaviour. Dental problems may be associated with

both positive and negative symptoms of

schizophrenia. Teeth are sometimes incorporated

into delusions and hallucinations. These include

delusions of pain, oral infestation by worms or

insects or bizarre delusions. Somatic delusions

about pain or other symptoms in the oral cavity may

result in unnecessary treatment. Bridges, crowns,fillings or extractionsmay be done, before the

psychiatric problem is recognized. Self-mutilationis

rare and may range from minor abrasions to self-

extraction of teeth and glossectomy.One patient

removed all his amalgam fillings with a watch-

makers screwdriver in the belief that transmitters

were in his teeth. Dentist needs to recognize the

disorder and proper referral be made.

Eating disorders

Dentists have a role in the early diagnosis of

eating disorders as they may be the first to observe

the effects of the illness. Anorexia nervosa reduces

serum calcium levels, predisposing to erosion of

tooth enamel and caries formation. Vitamin

deficiencies may cause bleeding gums, angular

cheilosis and a red sore tongue. In bulimia nervosa,

large quantities of soft sweet foods are often

consumed and vomited. Acidic gastric juices erode

the lingual aspect of the anterior maxillary teeth.

Hazelton and Faine20 reported that up to one-third

of people with bulimia had anterior tooth erosion.

To reduce abrasion of teeth and gingivae, it is

recommended that a mouthwash containing fluorideis used instead of tooth-brushing after vomiting.


7/39

Dental practitioners with special experience should

be available to treat patients in an eating disorders

service. Dental restorations, including crowns, a

fixed prosthesis or orthodontic appliances are

damaged by gastric acid. There fore, the patient

should be motivated and be recovering from their

illness well before being given expensivecosmetic

dental treatment.

Alcohol and substance misuse

Those who are dependent on drugs or alcohol

often neglect their personal hygiene and dietary

needs and may live in poor social conditions, all of

which contribute to poor oral health. Bruxism (tooth

grinding), gingivitis and tooth abscesses are more

common in those with alcohol dependency.

Smoking cigarettes and drinking alcohol increase

the risk of carcinoma of the oral cavity. Those who

take illicit opioids may require more analgesia thanexpected. This group of patients are quite difficult

to treat as they often present in an emergency with

the disease process in a more advanced condition.

Dental health behaviour

Regular brushing with a toothpaste containing

fluoride is important, as is the avoidance of frequent

intakes of cariogenic food or drink. Alcohol and

smoking are risk factors for oral disease. Special

care is needed for those taking medication with

xerostomic side-effects. Liquid forms of medication

without sugar should be chosen, whenever possible.

Good denture care should be part of routine physicalcare. Lucas21 reported that psychiatric patients who

wore dentures had more oral infections of

candidiasis, stomatitis and angular chielosis than

control subjects who did not wear dentures. These

painful conditions were worse in those who wore

dentures at night. Over half the females in the study

wore their maxillary dentures at night. It is

recommended that all dentures are removed at night

and cleaned before use.

Dental services

There have been major changes in the way in

which dental health services and treatment have

been provided since the inception of the National

Health Service in 1948. Significant advances have

been made in pain control, dental materials and

treatment modalities. Instead of general anaesthesia

for extractions, there is now widespread use of

sedation and local anaesthesia. There are also a

variety of techniques for treating people with dental

fear or phobia. In the late 1950s the high-speed drill

revolutionized the delivery of restorative dental

treatment and so an increasing proportion of the

population retained their teeth rather than havingextractions. The more recent development of


8/39

adhesive filling materials has further improved tooth

restoration and new veneer techniques have

increased the options for cosmetic dentistry. The

ability to anchor prostheses directly to the jawbone,

as a result of the development of osseo-integrated

implants, is a major advance. Paradoxically, while

the number of dental practitioners has steadily

grown, the increased complexity and range of care

Page 5has reduced the generalavailability of dental care

in the population. The following suggestions are

made to improve oral health status of the psychiatric

patients22,23.

Specific preventive dental programs should

be made an integral part of psychiatric

treatment and care.

The dental inspection and treatmentprotocol oftroops should be carried out

meticulously.

Application of appropriate preventive

measures like topical fluoride application,

fluoride mouth rinses and chlorhexidine

mouth rinses.

Better coordination between medical,

dental and psychiatric unit administration

to serve the needs of this group of patients.

References

1. Stiefel DJ, Truelove EL, Menard TW, et al.

Acomparison of the oral health of persons withand with out chronic mental illness in comm-

unity settings. Special Care Dentistry 1990; 10

: 6-12.

2. Sims A. Why the excess mortality from

psychiatric illness? BMJ 1987; 294 : 986-987.

3. Feinmann C, Harris M. Psychogenic facial pain

management and prognosis. Part 1. The Clinical

Presentation. Br Dental J 1984; 156 : 205-8.

4. Katon W, Ries RK, Kleinman A. Part11: a

prospective DSM-111 study of 100 consecutive

Somatisation patients. Compr Psychiatry 1984;

25 : 305-314.

5. Hiller W, Rief W, Fichter M. How disabled are

patients with Somato form disorders? Gen Hos

Psychiatry 1997; 19 : 432-438.

6. Bass C, Peveler R, House A. Somatoform

Disorders: Severe psychiatric illnesses

neglected by Psychiatrists. Br J Psychiatry

2001; 179 : 11-14.

7. Feinmann C (ed). The mouth, the face and the

mind. Oxford: Oxford University Press, 1999.

8. Bridges K, Goldberg DP. Somatic presentations

of psychiatric illness in primary care settings.J Psychosom Res 1988; 32 : 137-44.


9/39

9. Sensky T, Greer S, Cundy T et al. Referrals to

Psychiatrists in a general hospital- comparison

of two methods of liaison Psychiatry: Prelim

Commun J Royal Soc Med 1985; 78 : 463-468.

10. Gowda EM, Bhat PS, Swami MM. Dental

Health Requirements for Psychiatric Patients.

MJAFI 2007; 63 : 328-330.

11. Hede B. Oral health in Danish hospitalized

psychiatric patients.Comm Dental Oral Epide-

miol 1995; 23 : 44-8.

12. Sjorgren R, Nordstrom G. Oral health status of

psychiatricpatients. J Clin Nurs 2000; 9 : 632-

8.

13. Lussi A, Schaffner M, Hotz P, et Al. Dental

erosionin a population of Swiss adults. Comm

Dent Oral Epidem 1991; 19 : 286-290.

14. Papas AS, Joshi A, MacDonald SL, et al.

Cariesprevalence in xerostomicindividuals. SciJ 1993; 59 : 171-179.

15. Remick R A, Blasbery B, Patterson BD, et al.

Clinical aspects of xerostomia. J Clin Psy-

chiatry 1983; 44 : 63-65.

16. Slovin M. Managing the anxious and phobic

dentalpatient. New York State Dental J 1997;

63 : 36-40.

17. Enoch D, Jagger R. Psychiatric Disorders in

Dental Practice. Oxford: Butterworth-Heine-

mann Ltd 1994.

18. MooreR, Brodsgaard I, Rosenberg N. The con-

tribution of embarrassment to dental phobicanxiety: a qualitative research study. BMC

Psychiatry 2004; 19 : 10-14.

19. Ennekin P, Weinstein P, et al. Treatment

outcomes for specific subtypes of dental fear:

preliminary findings. Specia Care Dentistry

1992; 12 : 214-217.

20. Hazelton LR, Faine MP. Diagnosis and dental

management of eating disorder patients. Int J

Prosthodont 1996; 9 : 65-73.

21. John AL, Holt M. Follow up study of 1992

Dental Hygiene Graduates. Chicago: William

Rainey Harper College 1993.22. Hede B. Dental health behaviour and self-

reported dental health problems among hospita-

lised psychiatric patients in Denmark. Acta

Odontol Scand 1995; 53 : 35-40.

23. Markette RL, Dicks JL, Watson R C. Dentis-

tryand the mentally ill. Acad Gen Dentistry

1975; 23 : 28-30.DELHI PSYCHIATRY JOURNAL Vol. 14 No.1

APRIL 2011Delhi Psychiatry Journal 2011; 14:(1) Delhi Psychiatric Society


10/39


11/39


12/39


13/39


14/39

Ini adalah penelitian survey dengan rancangan cross sectional study yang bertujuan menilai

pengaruh gangguan cemas menyeluruh terhadap pola tekanan darah serta membandingkannya

dengan kelompok control yang tidak cemas. Diagnosa gangguan cemas menyeluruh ditegakkan

berdasarkan criteria diagnostic menurut PPDGJ III atau DCR-10.

Sasaran penelitian ini adalah semua pasien gangguan cemas yang datang berobat ke poliklinik

rawat jalan Rumah Sakit Jiwa Pusat Ujung Pandang, Sampel dirtarik secara random dengan


15/39

model penarikan cross over design.Data yang dikumpulkan diolah dan dianalisa dengan

menggunakan computer.

Dari penelitian ini didapatkan hasil 11 orang (35,5 %) pasien mempunyai tekanan darah diastolic

diatas nilai normal dan enam orang diantaranya disertai tekanan darah sistolik yang juga diatas

nilai normal. Tekanan darah rata-rata dari pasien dengan gangguan cemas menyeluruh adalah

lebih tinggi dari kelompok control yang tidak cemas.

Kesimpulan, pengaruh gangguan cemas menyeluruh terhadap pola tekanan darah secara

statistic tidak bermakna. Ada perbedaan tekanan darah antara kelompok kasus dengan

kelompok yang tidak cemas.

Kata kunci : GAD Otonomik Tekanan darah meningkat

Era globalisasi membawa dampak bagi perubahan interaksi sosial yang dapat menimbulkan

stres pada individu- individu tertentu. Stres ini dapat mempengaruhi fungsi dari berbagai system

organ tubuh, terutama system kardiovaskuler.

Selye dalam teorinya General Adaptation Syndrome atau Biological Stress Syndrome,

menjelaskan bahwa pada tahap awal(reaksi alarm ) reaksi fisiologik terhadap stres adalah

peningkatan aktivitas dari simpatetik adrenomedular merangsang sekresi adrenalin yang akan

menyebabkan peningkatan darah sistolik kemudian pada tahap kedua ( tahap perlawanan)

terjadi peningkatan aktivitas dari simpatetik adrenokortikal mengsekresi noradrenalin,

kortisol,aldosteron yang akan menyebakan peningkatan tekanan darah baik sistolik maupun

diastolik. Dan pada tahap ketiga ( tahap kelelahan), segala energi telah habis, tubuh menjadi tak

berdaya, organ- organ tubuh rusak, tekanan darah menurun dan pada akhirnya dapat membawa

kematian (1,2).

Manifestasi dari stress yang berkepanjangan dapat berubah anxietas (2,3). Anxietas adalah

suatu keadaan ketakutan tanpa adanya objek yang jelas. Respon fisiologik dijelaskan oleh

cannon (4).Menurut cannon, anxietas akan menimbulkan fight or flight. Flight merupakan reaksi isotonik

tubuh untuk melarikan diri, dimana terjadi peningkatan sekresi adrenalin kedalam sirkulasi darah

yang akan menyebabkan meningkatnya denyut jantung dan tekanan darah sistolik , sedangkan

fight merupakan reaksi agresif untuk menyerang yang akan menyebabkan sekresi noradrenalin,

rennin angiotensin sehingga tekana darah meningkat baik sistolik maupun diastolic (5).

Salan (6) meyatakan bahwa pada anxietas sedang terjadi sekresi adrenalin yang berlebihan

sehingga menyebabkan tekanan darah meningkat ,akan tetapi pada ketakuatn yang sangat

hebat bisa terjadi reaksi yang dipengaruhi oleh komponen parasimpatis sehingga menyebabkan

tekanan darah meningkat, akan tetapi pada ketakutan yang sangat hebat bisa terjadi reaksi yang

dipengaruhi olehj komponen parasimpatis sehingga menyebabkan tekanan darah menurun.Dari berbagai penelitian klinik yang pernah dilakukan mengenai pengruh stress atau anxietas

terhadap tekanan darah didapatkan hasil yang berbeda-beda. Sebagian besar peneliti

menemukan adanya peningkatan tekanan sistolik sebagi akibat dari peningkatan curah jantung

dan denyut jantung (7,8,9), sedangkan yang lainnya menemukan peningkatan tekanan diastolic

(10) dan ada juga yang tidak menemukan hubungan antara keduanya (11).

Pada penelitian yang membandingkan tekanan darah dari orang-orang yang menderita stress

atau anxietas dengan orang-orang yang tidak menderita stress atau anxietas didapatkan hasil

tekanan darah yang lebih tinggi pada kelompok penderita stress (12,13).

Adanya hasil yang berbeda-beda mengenai pengaruh anxietas terhadap tekanan darah ini

mendorong kami untuk melakukan penjelitian bagaimanakah pola tekanan darah pada gangguan


16/39

cemas menyeluruh yang merupakan salah satu bentuk daria anxietas dan bagaimana

perbandingannya bila dibandingkan dengan orang yang tidak cemas.]

Dipilihnya topik ini adalah karena :

1. Gangguan cemas menyeluruh merupakan gangguan anxietas yang prevalensasinya

cukup besar (3-8%).

2. Gangguan cemas menyeluruh perjalanan penyakitnya kronis dan derajat

kecemasannya relative stabil.

3. Adanya komplikasi kardivaskuler akibat stress atau anxietas yang mungkin dapat

membawa kematian.

Tujuan Penelitian

Penelitian ini bertujuan untuk :

1. Menilai pengaruh dari gangguan cemas menyeluruh terhadap tekanan darah baik

sistolik maupun diastolic.

2. Menilai apakah ada perbedaan tekanan darah antara penderita gangguan cemas

menyeluruh dengan kelompok control yang tidak cemas.

TINJAUAN PUSTAKA

A. ANXIETAS

Sejarah

Dari studi kepustkaan yang dibuat oleh Lewis pada tahun 1970, ditemukan bahwa istilah

anxietas mulai diperbincangkan pada permulaan abad ke-20. Kata dasar anxietas dalam bahasa

Indo Jerman adalah angh yang dalam bahasa latin berhubungan dengan kata angustus,

ango, angor, anxius, anxietas, angina. Kesemuanya mengandung arti sempit atau

konstriksi(13).

Pada tahun 1894, Freud menciptakan istilah anxiety neurosis. Kata anxiety diambil dari kata

angst yang berarti ketakutan yang tidak perlu(4). Pada mulanya Freud mengartikan anxietas

inu sebagai transformasi lepasnya ketegangan seksual yang menumpuk melalui system saraf

otonom dengan menggunakan saluran pernafasan. Kemudian anxietas ini diartikan sebagai

perasaan takut atau khawtir yang berasal dari pikiran atau keinginan yang direpresi. Akhirnya

nxietas diartikan sebagi suatu respon terhadap situasi yang berbahaya (4).

Definisi

Anxietas merupakan pengalaman yang bersifat subjektif (6,14,15,16), tidak menyenagkan

(4,6,16,17). tidak menentu (4.6.17,18), menakutkan dan mengkhawatirkan akan adanyakemungkuna bahaya atau ancaman bahaya (16,17), dan seringkali disertai oleh gejala-gejala

atau reaksi fisik tertentu akibat peningkatan aktifitas otonomik (4,6,16,18).

Klasifikasi

Menurut Diagnostic and Statistical Manual of Mental Disorder IV (DSM IV) terbagi atas :

1. Gangguan Panik dengan atau tnpa agorafobia.

2. Agorafobia tanpa riwayat gangguan panic.

3. Fobia Spesifik.

4. Fobia Sosial.

5. Obsesi kompulsif.

6. Gangguan stress pask trauma.7. Gangguan Cemas Menyeluruh(Generalized Anxiety Disorder).


17/39

8. Gangguan Cemas karena kondisi Medis Umum (Anxiety Disorder Duwe To Medical

Condition).

9. Gangguan cemas yang disebabkan oleh subtansi zat (Subtance Induced Anxiety Disorder).

dalam ICD-10(20), anxietas dimasukkan dalam kelompok Gangguan Neurotik, gangguan yang

berhubungan dengn stress dan Simatoform. Kelompok ini terbagi dalam :

1. Gangguan Anxietas Fobik yang terdiri atas :

a.Agorafobia dengan atau tanpa gangguan panic.

b.Fobia Sosial.

c.Fobi Spesifik.

2. Gangguan anxietas yang lain (Other Anxiety Disorder) yang terdiri atas :

a.Gangguan Panic(Panic Disorder).

b.Gangguan Cemas Menyeluruh (Generalized Anxiety Disorder).

c.Gangguan Campuran Anxietas dan Depresi ( Mixed Anxiety Disorder).

3. Gangguan Obsesi Kompulsif.

4. Gangguan Reaksi Menuju ke Stres Berat dan Gangguan Penyesuaian (Reaction to SevereStress, and Adjusment Disorder).

B. GANGGUAN CEMAS MENYELURUH

Definisi

Menurut DSM-IV yang dimaksud gangguan cemas menyeluruh adalah suatu keadaan ketakutan

atau kecemasan yang berlebih-lebihan, dan menatap sekurang-kurangnya selama enam bulan

mengenai sejumlah kejadian atau aktivitas disertai oleh berbagai gejala somatica yang

menyebabkan gangguan bermakna pada fungsi sosial, pekerjaan, dan fungsi- fungsi lainnya

Sedangkan menurut ICD-10 gangguan ini merupakn bentuk kecemasan yang sifatnya

menyeluruh dan menatap selam beberapa minggu atau bulan yang ditandai oleh adanya

kecemasan tantang msa depan, ketegangan motorik, dan aktivitas otonomik yang berlebihan.Epidemiologi

Gangguan cemas menyeluruh merupakan gangguan nxietas yang paling sring dijumpai, diklinik

diperkirakan 12 % dari seluruh gangguan anxietas. Prevalensinya di mas7yarakat diperkirakan 3

%, dan prevelansi seumur hidup (life time) rata-rata 5 % (19) .Di Indonesia prevalensinya secara

pasti belum diketahu, namun diperkirakan 2 % -5% (21).

Gangguan ini lebih sering dijumpai pada wanita dengan ratio 2 : 1, namun yang datang meminta

pengobatan rationya kurang lebih sama atau 1 :1 (4).

Etiologi

Etiologi dari gangguan ini belum diketahui secar pasti, namun diduga dua faktor yang berperan

terjadi di dalam gangguan ini yaitu, factor biologic dan psikologik (4 ,22).Faktor biologic yang berperan pada gangguan ini adalah neurotransmitter. Ada tiga

neurotransmitter utama yang berperan pada gangguan ini yaitu, norepinefrin , serotonin, dan

gamma amino butiric acid atau GABA (4,14,15,22). Namun menurut Iskandar (21)

neurotransmitter yang memegang peranan utama pada gangguan cemas menyeluruh adalah

serotonin sedangkan norepinefrin terutama berperan pada gangguan panic.

Dugaan akan peranan norepinefrin pada gangguan cemas didasarkan percobaan pada hewan

primata yang menunjukkan respon kecemasan pada perangsangan locus sereleus yang

memprm,,.mmm n pemberian obat-obatan yang meningkatkan kadar norepinefrin dapat

menimbulkan tanda-tanda kecemasan, sedangkan obat-obatan menurunkan kadar norepinefrin

akan menyebabkan depresi (23,24).


18/39

Peranan Gamma Amino Butiric Acid pada gangguan ini berbeda dengan norepinefrin.

Norepinefrin bersifat merangsang timbulnya anxietas, sedangkan Gamma Amino Butiric Acid

atau GABA bersifat menghambat terjadinya anxietas ini (4,14,15,25)Pengaruh dari

neutronstransmitter ini pada gangguan anxietas didapatkan dari peranan benzodiazepin pada

gangguan tersebut. Benzodiazepin dan GABA membentuk GABA-Benzodiazepin complexyang

akan menurunkan anxietas atau kecemasan(25). Penelitian pada hewan primate yang diberikan

sutau agonist inverse benzodiazepine Beta- Carboline-Carboxylic- Acid (BCCA) menunjukkan

gejala-gejala otonomik gangguan anxietas.

Mengenai perana serotonin dalam gangguan anxietas ini didapatkan dari hasil pengamatan

efektivitas obat-obatan golongan serotonergik terhedap anxietas seperti buspiron atau buspar

yang merupakan agonist reseptor serotorgenik tipe 1A (5-HT 1A).Diduga serotonin

mempengaruhi reseptor GABA-Benzodiazepin complex sehingga ia dapat berperan sebagai anti

cemas (4,14,25).Pemungkinan lain adalah interaksi antara serotonin dan norepinefrin dalam

mekanisme anxietas sebagai anti cemas (21).

Sehubungan dengan factor-faktor psikolgik yang berperan dalam terjadinya anxietas ada tiga

teori yang berhubungan dengan hal ini, yaitu : teori psikoanalitik, teori behavorial, dan teori

eksistensial.

Menurut teori psiko-analitik terjadinya anxietas ini adalah akibat dari konflik unconscious yang

tidak terselesaikan (4,6).

Teori behavior beranggapan bahwa terjadinya anxietas ini adalah akibat tanggapan yang salah

dan tidak teliti terhadap bahaya. Ketidaktelitian ini sebagai akibat dari perhatian mereka yang

selektif pada detil-detil negative dalam kehidupan, penyimpangan dalam proses informasi, dan

pandangan yang negative terhada[p kemampuan pengendalian dirinya (4).

Teori eksestensial bependapat bahwa terjadinya anxietas adalah akibat tidak adanya rangsang

yang dapat diidentifikasi secara spesifik.Ketiadaan ini membuat orang menjadi sadar akankehampaannya di dalam kehidupan ini (4,5).

Gambaran Klinik

Gambaran klinik dari gangguan ini ditandai oleh adanya ketakutan dan kecemasan yang

berhubungan dengan masa yang akan datang, gejala ketegangan motorik, hiperaktivitas system

saraf otonom dan meningkatnya kewaspadan (4,19,20).

Ketegangan motorik bermanisfetasi sebagai sakit kepala, gemetar dan gelisah. Gejala

hiperaktivitas system saraf otonom berupa jantung berdebar-debar, nafas pendek, berkeringat

banyak, dan berbagai gejala system pencernaan. Meningkatnya kewaspadaan ditandai dengan

adanya persaan mudah marah dan mudah terkejut (4,19,20).

Perjalanan PenyakitPerlangsungan dari gangguan ini bersifat kronis residif dan prognosisnya sukar diramalkan.

Sebanyak 25 % dari penderit ini mengalami gangguan panic (4).

Pengaruh Gangguan Cemas Menyeluruh terhadap Tekanan Darah.

Ada dua factor yang paling berpengaruh pada tekanan darah, yaitu curah jantung (cardiac

output) dan tahanan perifer (peripheral resistance) (26,27,28).

Kecemasan atau anxietas akan merangsang respon hormonal dari hipotalamus yang akan

mengsekresi CRF ( Cortisocoprin- Releasing Factor) yang meneybabkan sekresi hormon-

hormon hipofise. Salah satu dari hormon tersebut adalah ACTH (Adreno- Corticotropin Hormon).

Hormon tersebut akan merangsang korteks adrenal untuk mengsekresi kortisol kedalam

sirkulasi darah (2,15). Peningkatan kadar kortisol dalam darah akan mengakibatkan


19/39

[peningkatan renis plasma, angiotensin II dan peningkatan kepekaan pembuluh darah terhadap

katekolmin (26), sehingga terjadi peningkatan tekanan darah.

Selain itu hipotalamus juga berfungsi sebagi pusat dari system saraf otonom(15,29). Sistem ini

terbagi atas system simpatis dan system parasimpatis(23,30). Menurut Salan (26) pada anxietas

sedang terjadi sekresi adrenalin berlebihan yang menyebabkan peningkatan tekanan darah,

sedanngkan pada anxietas yang sangat berat dapat terjadi reaksi yang dipengaruhi oleh

komponen parasimpatis sehingga akan mengakibatkan penurunan tekanan darah dan frekuensi

denyut jantung. Pada kecemasan yang kronis kadar adrenalin terus meninggi, sehingga

kepekaan terhadap rangsangan yang lain berkurang dan akan terlihat tekanan darah meninggi.

Menurut Iskandar (21) pada Gangguan Cemas Menyeluruh yang terutama berperan adalah

neurotransmiter serotonin. Pada saat ini telah diidentifikasi tiga reseptor serotonin, yaitu : 5-HT1,

5-HT2dan 5-HT3(23,31). Menurut Kabo(33) reseptor 5-HT1bersifat sebagai inhibitor, sedangkan

reseptor 5-HT2dan reseptor 5-HT3bersifat sebagai eksitator. Menurut Gothert (31) aktivasi

reseptor 5-HT1akan mengurangi kecemasan sedangkan aktivasi reseptor 5-HT2akan

meningkatkan tekanan darah.

METODE

Subjek

Baik kelompok kasus maupun kelompok control diambil dari pengunjung poliklinik rawat jalan

Rumah Sakit Jiwa Ujung Pandang. Kelompok kasus dalah penderita gangguan cemas

menyeluruh sesuai dengan criteria diagnostic PPDGJ III dan DCR-10 (Diagnostic Criteria For

Research ICD-10). kelompok control adalah pengunjung poliklinik yang datang untuk

mendapatkan surat keterangan sehat dan bebas narkotik yang tidak cemas menurut HARS

( Hamilton Anxiety Rating Scale). Yang diamsukkan dalam penelitian ini adalah berusia 18 tahun

atau lebih, tidak menderita psikotik , tidak ada riwayat hipertensi dan gangguan lain yang dapat

meningkatkan atau menurunkan tekanan darah seperti Diabetes, hipertiroid, penyakit ginjal,anemia dsb.

Prosedur

Mula- mula dilakukan pengukuran tekanan darah baik terhadap kelompok kusus maupun

kelompok control. Pengukuran dilakukan dalam posisi duduk setelah istirahat selama lima menit.

Kemudian dilakukan wawancara untuk menegakkan diagnosis dan menilai derajat kecemasan

dengana menggunakan criteria diagnostic menurut PPDGJ III atau DCR-10 dan HARS.

Pengolahan data

Pengolahan data dilakukan secara elektronik dengan mengguna-kan computer melalui paket

statistic yang ada dalam program epi info versi 6, dan analisisnya dilakukan dengan

menggunakan SPSSpc+.Uji statistic yang digunakan adalah Kai kuadrat untuk uji kemaknaan gangguan cemas

menyeluruh terhadap tekanan darah dan student t test tidak berpasangan untuk meliht adanya

perbedaan tekanan darah antara kelompok kasus dengan kelompok control yang tidak cemas.

HASIL PEMBAHASAN

Selama penelitian ini telah diobservasi sebanyak 62 orang yang terdiri dari 31 orang kelompok

kasus dan 31 orang kelompok control.

Kebanyakan dari penderita gangguan cemas menyeluruh yang berkunjung ke poliklinik tersebut

adalah laki-laki(21 orang atau 64,5 %), dengan ratio 2 : 1 , sedangkan menurut literatur

(4,19,21,22) gangguan tersebut lebih banyak diderita oleh wanita dengan ratio 2 : 1, namun

yang datang berobat ke dokter rationya kurang lebih sama (1 : 1). Mungkin hal ini disebabkan


20/39

oleh karena sifat wanita yang kurang terbuka pada orang lain ataukah karena aktivitasnya yang

lebihbanyak untuk megurus rumah tangga, apalagi pada masyarakat timur.

Sebagian besar dari penderita gangguan tersebut adalah pengangguran (48,4 %) dan pada

umumnya merupakan kelompok usia dewasa muda (21-40 tahun) sebanyak 16 orang atau 51,6

%, dan dewasa pertengahan (41- 65 tahun) sebanyak 11 orang atau 38, 7 %. Ketiadaan

pekerjaan membawa individu kepada hampaan dalam kehidupan yang merupakan factor

psikososial bagi timbulnya kecemasan, sebagaimana dikemukakan dalam teori eksistesial (4,6).

Pada umumnya tekanan darah dari penderita gangguan cemas menyeluruh dalam batas normal,

hanya 11 orang atau 35,5 % yang mempunyai tekanan darah diatas batas normal. Semua dari

penderita yang tekanan darahnya diatas batas normal ini mempunyai tekanan diatolik 90 mmHg

keatas dan enam diantaranya mempunyai mempunyai tekanan sistolik 140 mmHg keatas.

Meskipun pada penelitian ini didapatkan adanya kenaikan tekanan darah sesuai dengan

meningkatnya kecemasan sebagi man dalam literature (7,8,910), namun pengaruh dari

gangguan dari anxietas ini secara statistic tidak bermakna.

Setelah dilakukan uji statistic dengan menggunakan student t test perbedaan tekanan darah

antara kelompok kasus ( sistolik rata-rata 118,7 mmHg dan diastolic 79,8 mmHg) dengan

kelompok control ( sistolik rata-rata 111,7 mmHg dan diastolic 71,00 mmHg), didapatkan hasil

adanya perbedaan yang bermakna secara statistic lebih tinggi pada kelompok kasus.

KESIMPULAN

Gangguan cemas menyeluruh lebih banyak diderita oleh kelompok dewasa muda dan umumnya

tidak mepunyai pekerjaan.

Meskipun gangguan anxietas ini secara statistic tidak mempengaruhi tekanan darah, namun

35,5 % dari penderita pada penelitian ini mempunyai tekanan diatolik diatas normal.

Tekanan darah penderita gangguan cemas menyeluruh secara bermakna lebih tinggi dari

kelompok yang tidak cemas.SARAN

1. Karena pengangguran (ketiadaan pekerjaan) tidak hanya menimbulkan dampak sosial

yang buruk tetapi juga dapat mengakibatkan gangguan psikis pada akhirnya mungkin dapat

menyebabkan penyakit fisik, perlu kiranya kerjasama yang baik antara berbagai pihak yang

terkait dalam masalah ini.

2. Sekalipun pengaruh gangguan cemas menyeluruh terhadap tekanan darah secara statistic

tidak bermakna, namun adanya penderita dengan tekanan diastolic diatas batas normal yang

jumlahnya cukup besar (35,5%), perlu kiranya diwaspadai adanya komplikasi hipertensi dimasa

yang akan datang dan perlu penanganan yang baik untuk gangguan cemas maupun

hipertensinya.3. Menyadari akan adanya kekurangan-kekurangan dalam penelitian ini baik dalam segi

prasarana maupun metode dan jumlah sample yang kecil. Perlu kiranya dilakukan penelitian

dengansampel yang lebih besar dan dengan prasaranan yang lebih baik.

DAFTAR PUSTAKA

1. Michael.M. : Stress Signs Source Sympton Solutions Editiones Roche, Basel Switzerland.

2. Hukom AJ : Patofiolegi Stress, Jiwa, Maret 1986, XIX : 1 33 42.

3. Mangindaan L. : Manisfetasi Klinik dari Stres, , Jiwa, Maret 1986, XIX : 1, 43- 54.

4. Kaplan HI, Sadock BJ. : Anxiety Disorder, Sypnosis of Psychiatry, 7thed, William & Wilkins,

Baltimore USA, 1994, 573-616.

5. Mardianti R. : Senang, Marah, dan Senang. Bagaimana Pengaruhnya Terhadap HipertensiAmbang? Jiwa, Maret 1990 XXIIII : 1, 49-52.


21/39

6. Salan. R : Beberapa Konsep Tentang Anxietas, Anxietas, Yayasan Dharma Usada, Jakarta,

1980, 12-23.

7. Falkner B, Ongesti C, Angelakos E. : Cardiovaskuler Respons To Mental Stress In Normal

Adolescent With Hypertensive Patient, Hypertensio 1978 : 1. 24 -30.

8. Knardahl S, Sanders AJ, Johnson AK : Efect Of Adrenal Demedullation On Stress Induced

Hypertension And Cardiovascular Reponses To Acute Stress, Acta Physiol Scand, 1988, 133,

77-83.

9. Folkow B. : Physiological Aspect Of Primary Hypertension Physiol Rev 1982. 62,3, 347-

504.

10. Steproe A, Melvile D, Ross A : Essential Hypertension And Psychological Functioning. A

study of factory workers, Br J Clinical Psychol 1982, 21 : 303 311.

11. Masterton G, Main CJ, Lever AF. : Low Blood Pressure In Psychiatric Inpatient, Br Heart J,

1981 ,45 : 442-446.

12. Timio M, Verdecchia P, Ronconi M. : Blood Pressure Change Over 20 Year In Mens In a

Secluded Order, J hypertensions 1985,3 (supplemen 8), 5387 -5388.

13. Anwar AH, Setyonegoro K. : Tiga dimenso Anxietas, Sebuah Pandangan Konsepsesual.

Dalam Anxietas ,K. Setyonegoro dan Y. Iskandar (ed). Yayasan Dharma Usada , Jakarta, 1980.

45-43.

14. Velucci SV,. : Anxiety in Neurotransmitter, Drug and disease. RA. Webster , CC. Jordan (ed).

Blackwell Scientific Publication . London, 1989, 394 -427.

15. Siverstone T, Turner P.: Anxiety. In Drug Treatment in Psychiatry, 4thed, Library of Congress

Cataloging in Publication Data Silverstone Trevor, London, 1993, 182- 200.

16. Solomon P : Anxiety Neurosis, Handbook of Psychiatry lange Medical Publication, California,

USA,1974, 216-218.

17. Noyes. : Modern Clinical Pshyciatry, WB Saunders Company, Philadhelpia, 1954, 442 -445.18. Cameron N, Rychlak Sf. : Anxiety Disorder, Personality Development and Psychopatology,

2nded, Houghton Mifflin Company, Boston, USA, 1985, 170-259.

19. American Pshyciatryc Association : Anxiety Disorder, Diagnostic and Statistical Manual of

Mental Disorder IV (DSM-IV), Washington , USA, 1994.

20. World Health Organization (WHO) : Anxiety Disorder, ICD-10 Classification of Mental

Disorders and Behavior Disorders, Geneva, 1994.

21. Iskandar Y ; Mengatasi Anxietas, Yayasan Dharma Graha, 1994.

22. Sharma R. : Anxiety state, In Pshyciatri Diagnosis & Therapy 88/89, JH Flaherty (ad),

Prentice Hall International Inc. USA, 1989, 84-95.

23. Ganong WF. : Review of medical Physiology , Prentice Hall International Inc. USA, 1991.24. Lader M. : Brain Organization and Bahavior, In Introduction to Psychompharmalogy,

Cambridge University Press, USA, 1996, 168 -215.

25. Stahl SM : Anxiolytic and Sedative-Hypnotic. In essential Psychompharmalogy Cambridge

University Press, USA, 1996 , 168-215.

26. Sidabutar RP. : Patofisiologi dan Patogenesis Hipertensi Yang Ada Kaitannya Dengan

Pengobatan, Simposium Nasional Hipertensi, PB IDI, Jakarta ,1993.

27. Susalit E : Epidemiologi, Etiologi dan Patofisiologi Hipertensi. Dalam Hipertensi, RP

Sidabutar (ed), Yayasan Penerbitan IDI,Jakarta,1991.

28. Kaplan NM. : Primary Hypertension Phatogenensis. In Clinical Hypertensions.Wiliiam &

Wilkins, Baltimore, USA, 1994, 47 -107.


22/39

29. Adams RD. : The Limbic Lobes and the Neurology of Emotions. In Princeples Neurology,

3rd(ed), Mcgraw Hill Book Company, New York,USA, 1993,381 -392.

30. Guyton Ac. : Human Physiology and Mechanism of Desease. WB Saunders Company, 1982.

31. Gothert M, Schlicker E. : Classification of Serotonin Receptors, In Serotonin in

Cardiovasculer Pharmacology, Raven Press, New York, 1987, 10 ;30 ; 58- 511.

32. Houston PS, Vanhoutta PM.: Serotonin the Puzzling Neurotransmitter , Its Roleing Vascular

- See more at:http://www.artikelkedokteran.com/304/pola-tekanan-darah-pada-gangguan-

cemas-menyeluruh.html#sthash.0B6iJJgy.dpuf

http://www.essenceofstressrelief.com/

Hans Selyes

General Adaptation Syndrome

Scientist Hans Selye(1907-1982) introduced the General Adaptation

Syndromemodel in 19! sho"in# in three phases "hat the alle#ed e$$ects o$ stress hason the %ody&

'n his "or Selye - *the father of stress research* de+eloped the theory that stress is amajor cause of disease because chronic stress causes long-term chemicalchanges.

He o%ser+ed that the %ody "ould respond to any e,ternal %iolo#ical source o$ stress "itha predicta%le %iolo#ical pattern in an attempt to restore the %odys internal homeostasis&

his initial hormonal reaction is your $i#ht or $li#htstress response - and its purpose is

$or handlin# stress +ery .uicly/ he process o$ the %odys stru##le to maintain %alanceis "hat Selyetermed the General Adaptation Syndrome&

ressures tensions and other stressors can #reatly in$luence your normal meta%olism&Selye determined that there is a limited supply of adaptive energy to deal withstress.hat amount declines "ith continuous e,posure&

Every stress leaves an indelible scar, and the organism pays for its survival

after a stressful situation by becoming a little older.

~ Hans Selye

Goin# throu#h a series o$ steps your %ody consistently "ors to re#ain sta%ility& iththe #eneral adaptation syndrome a humans adapti+e response to stress has threedistinct phases
http://www.artikelkedokteran.com/304/pola-tekanan-darah-pada-gangguan-cemas-menyeluruh.html#sthash.0B6iJJgy.dpufhttp://www.artikelkedokteran.com/304/pola-tekanan-darah-pada-gangguan-cemas-menyeluruh.html#sthash.0B6iJJgy.dpufhttp://www.artikelkedokteran.com/304/pola-tekanan-darah-pada-gangguan-cemas-menyeluruh.html#sthash.0B6iJJgy.dpufhttp://www.artikelkedokteran.com/304/pola-tekanan-darah-pada-gangguan-cemas-menyeluruh.html#sthash.0B6iJJgy.dpufhttp://www.essenceofstressrelief.com/http://www.artikelkedokteran.com/304/pola-tekanan-darah-pada-gangguan-cemas-menyeluruh.html#sthash.0B6iJJgy.dpufhttp://www.artikelkedokteran.com/304/pola-tekanan-darah-pada-gangguan-cemas-menyeluruh.html#sthash.0B6iJJgy.dpuf


23/39

ALA! S"AG# -

3our $irst reaction to stress reco#ni4es theres a dan#er and prepares to deal "ith thethreat a&&a& the $i#ht or $li#ht response& Acti+ation o$ the HA a,is the ner+ous system(S5S) and the adrenal #lands tae place&

6urin# this phase the main stress hormones cortisol adrenaline and noradrenaline is

released to pro+ide instant ener#y&

$f this energy is repeatedly not used by physical activity% it can become

harmful.

oo much adrenaline results in a sur#e o$ %lood pressure that can dama#e %lood +esselso$ the heart and %rain a ris $actor in heart attac and stroe&

he e,cess production o$ the cortisol hormonecan cause dama#e to cells and muscle

tissues& Stress related disorders and disease $rom cortisol include cardio+ascularconditions stroe #astric ulcers and hi#h %lood su#ar le+els&

At this sta#e e+erythin# is "orin# as it should you ha+e a stress$ul e+ent your %odyalarms you "ith a sudden olt o$ hormonal chan#es and you are no" immediatelye.uipped "ith enou#h ener#y to handle it&

#S$S"A&'# S"AG# -

he %ody shi$ts into this second phase "ith the source o$ stress %ein# possi%ly resol+ed&

Homeostasis %e#ins restorin# %alance and a period o$ reco+ery $or repair and rene"al

taes place&

Stress hormone le+els may return to normal %ut you may have reduced defensesand adaptive energy left.

'$ a stress$ul condition persists your %ody adapts %y a continued e$$ort in resistance andremains in a state o$ arousal&

ro%lems %e#in to mani$est "hen you $ind yoursel$ repeatin# this process too o$ten "ithlittle or no reco+ery& ltimately this mo+es you into the $inal sta#e&

#(HA)S"$*& S"AG# -

At this phase the stress has continued $or some time& 3our %odys a%ility to resist is lost%ecause its adaptation ener#y supply is #one& :$ten re$erred to as o+erload %urnoutadrenal $ati#ue maladaptation or dys$unction Here is where stress levels go upand stay up+

he adaptation process is o+er and not surprisin#ly; this stage of the generaladaptation syndrome is the most ha,ardous to your health.


24/39

here can also %e ad+erse $unction o$ the autonomic ner+ous system that contri%utes tohi#h %lood pressure heart disease rheumatoid arthritis and other stress related illness&

he pro#ressi+e sta#es o$ the #eneral adaptation syndrome clearly sho" "here ha+in#

e,cessi+e stress can lead& Gi+en a choice "hy "ould anyone purposely choose thispath= 3ou may "ant to chec out somerela,ation techni.uesor perhaps an her%al stress

relie$strate#y to help %rin# this under control&

he sources o$ stress are numerous "ith our hectic li$estyles %ut lucily there are ust asmany "ays to relie+e stress and still eep up and eep #oin#&

>motional >$$ects o$ Stress

ou are most liely to feelthe effects of stress when struggling with demandsthat e/ceed your natural ability to cope.

Ho" you percei+e those challen#es lar#ely depend on the $ormed attitudes you+eac.uired in li$e& ast con$licts may ha+e esta%lished a stron#hold o$ ha%itual ne#ati+ethou#hts and reactions&

?eco#ni4in# the $i#ht or $li#ht stress responseis ey in $i#htin# the e$$ects o$ stress and#ainin# %ac control&

0hat is stress and how does it affect mental health1

:ne de$inition o$ stress is

-- a physical or emotional element that causes bodily or mental tension and may be afactor in disease causation.

6id you #et that=

e dont usually +ie" our emotions as %ein# the reason $or #ettin# sic& 5e#ati+ity

carries so many harm$ul emotions such as an#er $rustration and "orry& his innerturmoil .uicly drains the mind and %ody o$ its a+aila%le ener#y& As a result o$ %ein#

increasin#ly on ed#e you also #ro" "eary in thou#ht and stamina&

God, grant me the serenity to accept the things I cannot change, the courage

to change the things I can, and the wisdom to know the difference.

~ einhold &iebuhr
http://www.essenceofstressrelief.com/relaxation-techniques.htmlhttp://www.essenceofstressrelief.com/herbal-stress-relief.htmlhttp://www.essenceofstressrelief.com/herbal-stress-relief.htmlhttp://www.essenceofstressrelief.com/fight-or-flight.html


25/39

echarging your depleted energy reserves

Special attention should %e placed on replenishin# the ener#y le+els that are %ein#e,hausted& >motional strain a$$ects e+eryone di$$erently&

here are distinct strate#ies in o%tainin# stress relie$ that "ill line up "ith your particularneed "hether its $or emotional tension physical tension or %oth&


26/39

Stress causes other common complications

3our %ed can %e +ie"ed as a %attle#round "hen com%atin# stress and insomnia& Bany"orries at %edtime "ill pre+ent the rela,ation needed $or a #ood ni#hts sleep& Sleepdepri+ation only intensi$ies the ad+erse e$$ects o$ stress&

'$ you are constantly #ettin# an#ry and ha+e a short $useD it could %e in part your

attitude/ 3ou may "ant to e,plore the reason "hy you are so .uic-tempered& 3ou canlearn to o+ercome this "ith #ood an#er mana#ement sills& @oo $or rela,in# "ays to

.uiet your a#itations& 3oull at least li+e your li$e happier i$ not lon#er too&

han$ully "e ha+e an a%undant ran#e o$ emotions at our disposal& here aretremendous health %ene$its mentally and physically $or stayin# optimistic& So try to%ecome more a"are o$ "hen you are %ein# pessimistic in your +ie"s&

"!dversity is inevitable, but stress is optional"

~ )nnown

$n conclusion% here2s what to do3

ant to remain in the %est possi%le $rame o$ mind=

Guard yoursel$ $rom the emotional %ad e$$ects o$ stress& 3ou cannot al"ays control the

ad+ersity that comes into your li$e %ut you can choose ho" you are #oin# to react to it&

Sel$-a"areness is a #ood place to start&

>+aluate "hat your causes o$ stress are

Start mana#in# stress appropriately

Get some #ood stress relie+ers "orin# $or you/

he intricate "orin# o$ your mind emotion mood and %eha+ior all inter"o+ento#ether is +ery comple,&

lease reali4e that your o+erall "ellness is a$$ected and re#ulated in many po"er$ul "ays$rom the emotional e$$ects o$ stress& And it all closely ties in "ith the physiolo#icalchan#es o$ the $i#ht or $li#ht response&

hysical >$$ects :$ Stress

Having control over the ravaging physical effects of stress is a valid concern if

you suffer from significant amounts of tension in your life.

'ts %een estimated that nearly 80-90E o$ our +isits to the doctor are due to stressrelated illness or conditions& Sta##erin# is the $act that most sicness and disease can %e


27/39

traced to a root cause o$ emotional distress&

hat #oes on in your physical %ody is #reatly in$luenced %y the po"er$ul mind-%odyconnection& 3ou can literally "orry yoursel$ into an early #ra+e& he actual physicale$$ects o$ stress on health can %e e,tremely dama#in#& 't is o$ the utmost importancethat you help your %ody $unction the "ay it "as meant to&

earn to rela#. $our body is precious, as it houses your mind and spirit. Inner

peace begins with a rela#ed body

~&orman 4incent 5eale

How does stress affect health1

3our %rain sees to chemically re#ulate that elusi+e %alance %et"een stimulatin# and

tran.uili4in# your %ody& Adustments are made "hene+er somethin# distur%s themeta%olic e.uili%rium no"n as homeostasis&

hen a threat arises the sympathetic ner+ous system (S5S) launches the$i#ht-or-$li#htresponse& his prepares you $or .uic action %y speedin# the heart rateconstrictin# %lood +essels decreasin# di#esti+e acti+ity and raisin# %lood pressure&+er notice that stress and acneseem to #o hand in hand "hen youre an,ious o+ersome%i# e+ent= :ther sin conditions such as psoriasis rosacea and ec4ema can also %ea##ra+ated "hen youre under pressure& And the o$ten-ased .uestion F


28/39

~Astrid Alauda

re.uently your appetite is a$$ected %y stress and "ei#ht loss occurs& :n the other handyou mi#ht $ind yoursel$ cra+in# so-called com$ort $oods and o+ereatin#& eedin# your%ody the proper amount o$ $ood and nutrients start "ith sel$-a"areness& ry eepin#trac o$ "hat tri##ers cause your eatin# ha%its %y "ritin# it do"n&

Stress and "ei#ht #ain can #rossly contri%ute to o%esity and complicate health pro%lems&A hi#h incident o$ %ody $at speci$ically stu%%orn %elly $at is associated "ith the hormonecortisol and meta%olic syndrome&

he physical e$$ects o$ stress "eaens your immune system& 3ou are much more

+ulnera%le to colds and other in$ections& hus your a%ility to $i#ht impendin# disease is#reatly diminished and compromised&

5hysiological #ffects of Stress and 5remature Aging

Stress e$$ects the %ody %y speedin# up the normal occurrence o$ o,idation& ree radicals

run rampant creatin# e,cessi+e "ear and tear on internal or#ans and systemsthrou#hout your %ody& hen your distressed the +ery 65A "ithin your cells is under

attac/

0eaened and abnormal cells divide and multiply3 an invitation for cancer+

Aller#ies asthma and autoimmune diseases may %ecome increasin#ly se+ere& ith hi#hand prolon#ed le+els o$ stress health helplessly su$$ers in some "ay as %odily $unctions

are altered and %e#in to $ail&

his accelerates the a#in# process and %rin#s on a#e-related disease/

5hysical symptoms of stress and illness6

Adrenal $ati#ue symptoms- occur "hen o+er-stimulated adrenal #lands ha+e

reached e,haustion and no lon#er $unction properly

Crain cell dama#e or death in the hippocampus - the area o$ your %rain needed$or memory concentration and learnin#&


29/39

Hi#h (@6@) cholesterol tri#lycerides

'nsomnia $ati#ue poor sleep

Se,ual dys$unction disorders BS in$ertility

"&ake care of your body. Its the only place you have to live"

~7im ohn

&eutrali,e the side effects of stress

3ou can #reatly impro+e your health and help counteract the physical e$$ects o$ stress %y

tain# control o$ your health "ith a holistic approach in medicine&

@earn to use stress reduction techni.ues&'t may re.uire some e$$ort on your part

to initiate your rela,ation response %ut tae this seriously& 3our health is the mostprecious commodity you o"n& 't is "orth it/

ae steps to ade.uately nourish your %ody and promote the replication o$ +i%rant

and healthy ne" cells& 't is crucialnot only %ut especiallydurin# stress$ul situationsto neutrali4e and protect each and e+ery cell $rom the de+astation o$ $ree radicals&

>,ercise daily

Get ade.uate sleep each ni#ht

hese are +ery $undamental "ays in preser+in# +itality and eepin# the physical e$$ects

o$ stress at %ay& '$ you truly "ant to a+oid %ein# one o$ the many health statistics onstress thenD


30/39

e-stage reaction to stress. Selye e1plained his choice of terminology asfollows: 23

call this syndrome generalbecause it is produced only by agents which ha!e a g

eneral eect upon largeportions of the body. 3 call it adaptivebecause it stimulat

es defense4. 3 call it a syndromebecause its indi!idualmanifestations are coordi

nated and e!en partly dependent upon each other.2

Selye thought that the general adaptation syndrome in!ol!ed two ma5or systems

of the body, the ner!ous system and theendocrine &or hormonal system. %e the

n went on to outline what he consideredas three distincti!e stages in thesyndro

me's e!olution. %e called these stages the alarm reaction &A6, the stage of resis

tance &S6, and the stage ofe1haustion &S7.

Stage 1: alarm reaction (ar)

8he 9rst stage of the general adaptation stage, the alarm reaction, is the immedi

ate reaction to a stressor. 3n the initialphase of stress, humans e1hibit a 29ght or

ight2 response, which prepares the body for physical acti!ity. %owe!er, thisinitial response can also decrease the eecti!eness of the immune system, ma#ing pe

rsons more susceptible to illnessduring this phase.

Stage 2: stage of resistance (sr)

Stage might also be named the stage of adaptation, instead of the stage of resi

stance. ;uring this phase, if the stresscontinues, the body adapts to the stressor

s it is e1posed to. hanges at many le!els ta#e place in order to reduce theeect

of the stressor. uite appealing and en5oyable to someone else. oo#ing at one'sresp
http://medical-dictionary.thefreedictionary.com/general+adaptation+syndromehttp://medical-dictionary.thefreedictionary.com/general+adaptation+syndromehttp://medical-dictionary.thefreedictionary.com/general+adaptation+syndromehttp://medical-dictionary.thefreedictionary.com/stresshttp://medical-dictionary.thefreedictionary.com/general+adaptation+syndromehttp://medical-dictionary.thefreedictionary.com/stresshttp://medical-dictionary.thefreedictionary.com/starvation


31/39

onses to speci9c stressors can contribute to better understanding of one's partic

ular physical, emotional, and mentalresources and limits.

Causes and symptoms

Stress is one cause of general adaptation syndrome. 8he results of unrelie!ed str

ess can manifest as atigue, irritability,di"culty concentrating, and di"culty sleeping. ?ersons may also e1perience other symptoms that are signs of stress.?ers

ons e1periencing unusual symptoms, such as hair loss, without another medical

e1planation might consider stressas the cause.

8he general adaptation syndrome is also inuenced by such uni!ersal human !ar

iables as o!erall health and nutritionalstatus, se1, age, ethnic or racial bac#groun

d, le!el of education, socioeconomic status &S7S, genetic ma#eup, etc.Some of t

hese !ariables are biologically based and di"cult or impossible to change.


32/39

Treatment

8reatment of stress-related illnesses typically in!ol!es one or more stress

reductionstrategies. Stress reductionstrategies generally fall into one of three c

ategories: a!oiding stressors@ changing one's reaction to the stressor&s@ orrelie!i

ng stress after the reaction to the stressor&s. Bany mainstream as well as compl

ementary or alternati!e &ABstrategies for stress reduction, such as e1ercising, l

istening to music, aromatherapy, and massage relie!e stress afterit occurs.

Bany psychotherapeutic approaches attempt to modify the patient's reactions to

stressors. 8hese approaches ofteninclude an analysis of the patient's indi!idual p

atterns of response to stress@ for e1ample, one commonly used set ofcategories

describespeople as 2speed frea#s,2 2worry warts,2 2cli wal#ers,2 2loners,2 2bas#

et cases,2 and 2drifters.27ach pattern has a recommended set of s#ills that the p

atient is encouraged to wor# on@ for e1ample, worry wartsaread!ised to reframe

their an1ieties and then identify their core !alues and goals in order to ta#e concr

ete action about theirworries. 3n general, persons wishing to impro!e their management of stress should begin by consulting a medicalprofessional with whom th

ey feel comfortable to discuss which option, or combination of options, they can

use.

Selye himself recommended an approach to stress that he described as 2li!ing wi

sely in accordance with natural laws.2 3nhis now-classic boo# The Stress of Life&

(CD, he discussed the following as important dimensions of li!ing wisely:

Adopting an attitude of gratitude toward life rather than see#ing re!enge for in5uries or slights.

Acting toward others from altruistic rather than self-centered moti!es.

6etaining a capacity for wonder and delight in the genuinely good and beautiful things in life.


33/39

Periodicals

Henton, 8ami ;., B;, and Jac>ueline ynch, BS. 2Ad5ustment ;isorders.2 eMedi

cineSeptember 0, ))F.http:emedicine!commedtopic""#$!htm .

osen-Hin#er, . 3., B. G. Hin#er, G. Iegri, and $. 8iscornia. 23nuence of Stress in

Acute ?ancreatitis and orrelationwith Stress-3nduced Gastric Klcer.2 PancreatologyF &July ))F: F*)-FF.

Bot=er, S. A., and L. %ertig. 2Stress, Stress 6esponse, and %ealth.2 Nursing Clinic

s of North America0( &Barch ))F:-*.

Mates, illiam 6., B;. 2An1iety ;isorders.2 eMedicineAugust C, ))F. http:e

medicine!commedtopic%&'!htm .

Organiations

American 3nstitute of Stress. F ?ar# A!enue, Mon#ers, IM )*)0 &(F (D0-

)).


34/39

,tressorN A stimulus or e!ent that pro!o#es a stress response in an organism.

Stressors can be categori=ed as acuteor chronic, and as e1ternal or internal to th

e organism.

Gale 7ncyclopedia of Bedicine. opyright )) 8he Gale Group, 3nc. All rights

reser!ed.

general adaptation syndrome

all nonspeci9c systemic reactions of the body to prolonged systemic stress, inclu

ding the +/+R0R.+CT123, resistance, ande1haustion.

Biller-Eeane 7ncyclopedia and ;ictionary of Bedicine, Iursing, and Allied %ealth,

Se!enth 7dition. O ))0 by Saunders, an imprint of 7lse!ier, 3nc. All rights

reser!ed.

genPerPal adPapPtaPtion synPdromea syndrome introduced by %ans Selye to describe a single mar#ed physiologic re

sponse in the pituitary-adrenalsystem, as a result of e1posure to a !ariety of prol

onged physical or psychological stresses or stressors, with thebodily changes pro

gressing through three stages that the author described as the alarm reaction, re

sistance, and9nally e1haustion. See: stress&F, stress&C. ompare: psychoen

docrino(ogy.

Synonym&s: adaptation syndrome o ,e(ye


35/39

&0 71haustion stage or burn out, in which the immune systems lose all defensi!e

capabilities, accompanied by multi-systemshutdown.

Banagement

6educe stress.

Segen's Bedical ;ictionary. O )


36/39

%e elo>uently e1plained his stress model, based on physiology and psychobiology, as the General Adaptation

Syndrome &GAS, stating that an e!ent that threatens an organismXs well being, a stressor, leads to a three-stage

bodily response:

,tages o *+,: Alarm

Kpon percei!ing a stressor, the body reacts with a V9ght-or-ightW response and the sympathetic ner!ous system is

stimulated as the bodyXs resources are mobili=ed to meet the threat or danger.

: 6esistance

8he body resists and compensates as the parasympathetic ner!ous system attempts to return many physiological

functions to normal le!els while body focuses resources against the stressor and remains on alert.

0: 71haustion

3f the stressor or stressors continue beyond the bodyXs capacity, the resources become e1hausted and the body is

susceptible to disease and death.

.vo(ving the Defnition o ,tress

As 3 enter my Fth year of practice 3 am con!inced that the traditional of de9nition of stress, simply geared towards a

physical e!ent or a mental state re>uiring the body to respond 5ust doesnXt cut it anymore. e li!e in a society where

there are stressful inuences coming at us from all dierent directions. 8hese stressors are multiple and confounded.

Ba#ing the issue worse, is the way 3 see patients choosing to respond to their perception of stress. 8he increase use of

alcohol, drugs, cigarettes, sugar and energy drin#s in response to dealing with e!eryday stressors is creating an e!en

more stressful situation in the body. hether the stress, percei!ed as good or bad, or it is passi!e or acti!e, the

response by our bodies is intended to preser!e life@ it is a sur!i!al mechanism.

The 4uman ,tress Response

8he human stress response in!ol!es many components, as SelyeXs wor# portrayed.


37/39

and pituitary acti!ate another part of the adrenals, releasing cortisol. 8his is followed by the ner!ous system initiating

beha!ioral responses li#e alertness, focus, reduction of pain receptors and the inhibition of reproducti!e beha!iors and

desires. 8he sympathetic ner!ous system then #ic#s in to increase the heart rate, blood pressure and release fuel to

help 9ght or get out of danger as it redirects blood ow to the heart, muscles and brain, away from the gastrointestinal

tract and digesti!e processes. 8o accommodate these demands there is a !ast increase in energy production and

utili=ation of nutrients and uids in the body. $nce the stressful situation has passed, the brain signals the responses to

be Vturned oW and 9nally reco!ery and rela1ation allow the body to re-establish balance in all systems, replacing lost

nutrients and eliminating waste products accumulated during the process.

The 0issing Response ,tage

8he #ey element in this stress response that is missing in our modern day stress paradigm is 67$L76M. hile there

are usually reco!ery times for life threatening e!ents li#e getting chased by a polar bear, there are few for the

recurring e!ents li#e bac#ed up tra"c, relationship troubles, 9nancial pressures, 5ob stresses, negati!e self-tal# and

image, poor physical conditioning, arti9cial lighting, malnourished diet, inade>uate sleep, genetically modi9ed foods,

en!ironmental to1in accumulation and so on.

3n fact, these types of stressors each day can string themsel!es together rendering the stress response to be Vturned

onW all of the time. 3n ))*, the American ?sychological Association &A?A commissioned its annual nationwide sur!ey

to e1amine the state of stress across the country. 8he #ey 9ndings were noted as V?ortrait of a Iational ?ressure

oo#erW with almost )Y of the people sur!eyed reporting e1periences of physical symptoms due to stress. 3 belie!e

that modern day stress is the up stream culprit of many of the down stream chief complaints 3 see e!ery day in my

practice.

As practitioners, 3 belie!e we ha!e to ha!e a healthy respect for the great wor# of people li#e ;r. Selye and his General

Adaptation Syndrome &GAS and treat what we #now as clinical inuencers in our modern day. ?erhaps VGASW could

also stand for Guidelines Against Stress and could help our patients maintain healthy stress le!els and responses by

encouraging and educating each patient to identify and decrease unrelenting stressors. Also, we can help by re-

pleating stress-induced nutrient depletions including !itamin , pantothenic acid, calcium, and magnesium as well as

supporting healthy deto1i9cation pathways and adrenal function.Z%erbal adaptogen options such as 6hodiola rosea

and %oly basil. further support the stress response.Z

4o((y /uci((e5 3D R3

;r. %olly belie!es in the science, art and mystery of healing and has a heartfelt passion for the indi!idual wellness of all

people. Huilt on this foundational belief, ;r. %ollyXs pri!ate practice in os Angeles, %ealing from ithin %ealthcare,


38/39

focuses on comprehensi!e naturopathic medicine and indi!iduali=ed care. $utside of her practice, ;r. %olly holds a

position on the American Association of Iaturopathic ?hysicians board of directors and she is also on the faculty of the

Global Bedicine 7ducation


39/39

ontinually high cortisol levels lead to suppression of the immune system through increasedproduction of interleuin-, an immune-system messenger. This coincides with research findingsindicating that stress and depression have a negative effect on the immune system. 2educedimmunity maes the body more susceptible to everything from cold and flu to cancer. 3or example,the incidence of serious illness, including cancer, is significantly higher among people who havesuffered the death of a spouse in the previous year. 3ortunately, this immune-suppression process

can be corrected with psychotherapy, medication, or any number of other positive influences thatrestore hope and a feeling of self-esteem. The ability of human beings to recover from adversity isremarable.

Thus, very often, those under severe, prolonged stress may contract diseases related to immunedeficiency and may even die of these diseases. The death does not come from stress itself. Whathappens is that the body loses all its resistance in its effort to ward off the stress. Thus the personsdie of immune deficiency causes such as infection, cancer etc. "o, it is very important that werecognie the cause for stresses and remove the causes to maintain a healthy lifestyle.

&nother result of stress is the clogging of the arteries by the fat and cholesterol released by the

body during the attempt to fight stress. This may result in a heart attac or you may suffer a stroe

by losing blood supply to the brain. !any people start drining to combat the stress. "tress can alsomanifest itself into a number of diseases 5 depression, headaches, insomnia, ulcers, asthma, and

more.

(J) Psychological and Physiological of a Head Down Titled Condition

Documents

Transcript of (J) Psychological and Physiological of a Head Down Titled Condition