(j) psychological and physiological of a head down titled condition
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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
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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
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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
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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
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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
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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.
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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
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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
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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.
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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
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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
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4. Katon W, Ries RK, Kleinman A. Part11: a
prospective DSM-111 study of 100 consecutive
Somatisation patients. Compr Psychiatry 1984;
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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
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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.
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9. Sensky T, Greer S, Cundy T et al. Referrals to
Psychiatrists in a general hospital- comparison
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Commun J Royal Soc Med 1985; 78 : 463-468.
10. Gowda EM, Bhat PS, Swami MM. Dental
Health Requirements for Psychiatric Patients.
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11. Hede B. Oral health in Danish hospitalized
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12. Sjorgren R, Nordstrom G. Oral health status of
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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-
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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
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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
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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
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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).
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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).
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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
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[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
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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.
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29. Adams RD. : The Limbic Lobes and the Neurology of Emotions. In Princeples Neurology,
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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
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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.
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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 -
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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&
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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 >$$ects :$ Stress
Having control over the ravaging physical effects of stress is a valid concern if
you suffer from significant amounts of tension in your life.
'ts %een estimated that nearly 80-90E o$ our +isits to the doctor are due to stressrelated illness or conditions& Sta##erin# is the $act that most sicness and disease can %e
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traced to a root cause o$ emotional distress&
hat #oes on in your physical %ody is #reatly in$luenced %y the po"er$ul mind-%odyconnection& 3ou can literally "orry yoursel$ into an early #ra+e& he actual physicale$$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
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~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#&
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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
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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 -
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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.
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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.
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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-
)).
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,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
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&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 )
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%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.
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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,
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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
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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.
¬her 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.