MEDICAL AND HEALTH SCIENCE JOURNAL 2023 FEBRUARY, VOL 07 (01) Medical and Health Science Journal Available at http://journal2.unusa.ac.id/index.php/MHSJ; DOI: 10.33086/mhsj.v7i1.3558 pISSN 2549-7588. eISSN 2549-7596 CASE REPORT PSYCHODYNAMIC OVERVIEW OF GENERALIZED ANXIETY DISORDER IN YOUNG ADULTS Era Catur Prasetya 1, Rizky Dwi Lestari *1, Muhammad Hanun Mahyuddin 2, Ulaa Haniifah 2, Olga Putri Atsira 2 1Department of Psychiatry, Faculty of Medicine, Universitas Muhammadiyah Surabaya, Indonesia 2Faculty of Medicine, Universitas Airlangga Surabaya, Indonesia *Correspondent Author: rizkydwilestari21@gmail.com ARTICLE INFO Article history: Received: October 18, 2022 Received in revised form: February 22, 2023 Accepted: March 28, 2023 Keywords: Anxiety Disorder, Generalized Anxiety Disorder, Adult Individual ABSTRACT The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines an anxiety disorder as an excessive feeling of fear that occurs in a person that interferes with daily activities. Generalized anxiety disorder causes a person to feel anxious about a wide range of situations and issues. Patients often experience anxiety, feelings of fear and constantly on edge, difficulty concentrating, difficulty sleeping, muscle tension, and frequent irritability. Based on data from the Indonesian Ministry of Health in 2007, there were 450 million people who had to live with mental disorders. The prevalence of adult individuals (aged 18 years and over) and the elderly, there were 11.6% who experienced emotional disorders, such as anxiety and depression. This case report discusses a 20-year-old woman with the main complaint of unclear anxiety, not knowing what to worry about, floating between things she worries about is death, fear of having a serious illness, breakup, fear of losing her job as a content creator, and feeling of being blamed that keeps on coming. Management in the form of giving SSRI antidepressants and psychodynamic psychotherapy is done to try to reinterpret feelings of guilt that often arise as a result of fixation in one phase of their growth and development. Medical and Health Science Journal INTRODUCTION Anxiety is a persistent feeling of worry as a response to threats or stressors that can come from within the individual or the environment. Anxiety is a normal and pathological response depending on its intensity, duration and the individual's ability to cope. Anxiety is a pathological condition characterized by feelings of fear accompanied by a hyperactive autonomic nervous system. Anxiety is also an emotional reaction arising from non- specific causes such as subjective individual experiences that can cause feelings of discomfort and threatened. About 2/3 of adolescents and young adults with anxiety disorders do not seek help and only a few report contact with a psychotherapist (1). Almost all individuals have experienced anxiety, especially as a result of accumulated life problems (2). Meanwhile, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines an anxiety disorder as an excessive feeling of fear that occurs in a person which has an impact on disrupting their daily activities. Anxiety disorders can be experienced by many individuals regardless of age or gender. The causes of this anxiety disorder are quite varied. Therefore, the DSM-5 divided this anxiety disorder into several types, namely phobias, social anxiety disorder, separation anxiety disorder, panic disorder, and generalized anxiety disorder (3). Based on data from the Ministry of Health of Indonesia in 2007, there were 450 million people who had to live with mental disorders. The prevalence of adult individuals (aged 18 years and over) and the elderly, there were 11.6% who experienced emotional disorders, such as anxiety http://journal2.unusa.ac.id/index.php/MHSJ Saini et al MEDICAL AND HEALTH SCIENCE JOURNAL 2023 FEBRUARY VOL.07 (01) Page 47 of 53 and depression (4). Basic Health Research on adult individuals in Indonesia shows an increase in emotional disorders, in 2013 by 6% and in 2018 by 9.8% with the most common symptoms being headaches, sleep problems, decreased appetite, and fatigue (5). One in five teens experiences moderate to severe anxiety during the COVID-19 pandemic. There are some differences in anxiety levels among adolescents by region and income level, highlighting the need for targeted public health interventions based on nationally identified priorities (6). One in five Indonesians may experience anxiety during the COVID-19 pandemic. The groups most at risk are young women, people suspected of having COVID-19, and those with unsatisfactory social support. However, health workers were found to have a lower risk of experiencing anxiety because they have a better level of self-awareness. Accessible health information and care, social connections, a supportive environment, and mental health surveillance are important for preventing larger post-pandemic psychiatric problems (7). CASE(S) Today's teens and young adults are more tech- savvy than any previous generation; however, any discussion of technology should acknowledge concerns about potential negative consequences for psychological health (8). A 20-years-old woman, a 5th-semester student, unmarried, Muslim, came independently to the outpatient polyclinic of Muhammadiyah Lamongan Hospital with a complaint of anxiety. The patient lives at home with her mother, sister, grandmother, and grandfather. The patient's father migrated for work since the patient was still in the womb and returned home every 2 years, but since the corona pandemic, it has been a long time since he last went home. Generalized mental disorders are very common among young adults in their twenties, and less frequently in their thirties/forties. Those who develop mental disorders in their twenties have a higher risk of developing them ten years later. This has significant implications for young people's abilities to obtain an education, raise a family, and participate in work life (9). Patients are cared for by a mother who tends not to talk much and is typical of a rural mother who spends more time in the fields than at home. The patient admits that she sometimes feels that she has lost her father figure, someone who should be with her all the time, especially when the patient remembers her childhood when she was in trouble and there was no place to complain. Although, sometimes, there is a feeling of freedom because she feels that by being left alone, there is no one who can control her life, and instead, feels happy about it. She is the type of patient who likes to be alone and only communicates with others when she is in absolute need. In 2019, the patient started complaining of shortness of breath and shaking. She was afraid, thinking it was a symptom of heart disease. Then the patient went to an internist and was diagnosed with gastric disease. However, the patient said that she believed she had a mental disorder. Later that year, the patient developed a relationship with someone, but the patient did not dare to talk to her partner regarding the patient's mental condition, and she only told her partner about her gastric disease. Therefore, the patient still feels alone despite being in a relationship and having no friends to confide in. One month ago, the patient's boyfriend was caught cheating with someone else. The patient was angry and then experienced an anxiety disorder that felt unclear until it interfered with her daily activities as a student at one of the public universities in Surabaya. Psychiatric status obtained an appearance that was in accordance with her age, clean and neat clothes, wearing a hijab, and a mask. The patient is compos mentis with GCS 456. Behavior and psychomotor activity before, during, and after the interview, showed the patient sitting quietly with both hands on her thighs. When interviewed, the patient was cooperative with the examiner, was open, told the current problems calmly, and answered according to the examiner's questions in a voice that was enough to be heard. Saini et al MEDICAL AND HEALTH SCIENCE JOURNAL 2023 FEBRUARY VOL.07 (01) Page 48 of 53 Overall, the patient's speech was good, it was coherent, and no speech disturbance was found. The patient's feeling (mood) was in a euthymic state where the patient's sense of feeling is broad and congruent with the rhythm of her life, broad affect, broad emotional expressions with variations in facial expressions, voice rhythms, and body movements in harmony with the atmosphere, these can conclude the congruent between mood and affect. There were no perceptual disturbances in the patient such as hallucinations (-) and illusions (-). The patient's intellectual function, both sensory and cognitive, was good. The patient's thought process consists of a coherent stream of thought, and preoccupation thought related to her shortness of breath. The patient is able to control impulses. The value of the observation on the patient is grade 6 where the patient is fully aware of the situation with the motivation to achieve improvement. The patient's physical status and neurological status were within normal limits. The patient's multiaxial diagnosis is: axis I F41.1 Generalized anxiety disorder. Axis II Anxiety (avoidance) personality traits. Axis III K00-K93 Diseases of the digestive system. Axis IV Problems related to the social environment. Axis V GAF Scale 70-61 Some mild and persistent symptoms, mild disability in function, generally still good. DISCUSSION Generalized anxiety disorder is an anxiety disorder characterized by the appearance of excessive feelings of anxiety when going to do a job or activity (3). Generalized anxiety disorder causes a person to feel anxious about a wide range of situations and issues. Patients often experience anxiety, feelings of fear and constantly on edge, difficulty concentrating, difficulty sleeping, muscle tension, and frequent irritability (10). Based on the DSM-5, there are six criteria for someone to be diagnosed with generalized anxiety disorder. First, excessive anxiety and restlessness for several days in the past six months. Second, difficulty in controlling feelings of anxiety and restlessness. Third, feeling of anxiety and restlessness appears with at least three other symptoms, such as feeling depressed, the body easily feels tired, difficulty concentrating, irritability, muscle tension, and sleep disturbances. Fourth, feelings of anxiety, restlessness, and other physical symptoms cause disruption in carrying out social and occupational functions in daily life. Fifth, not caused by any other medical condition. Sixth, this disorder cannot be explained by other mental disorders (3). There are three psychological theories about the causes of anxiety: 1) Sigmund Freud's psychoanalytic theory Freudian psychology is a science based on the unconscious (id) and consciousness (ego) (11). Defines anxiety as a sign of unconscious danger. Anxiety is seen as the result of a mental conflict between aggressive desires or unconscious sexual urges and concurrent threats from the superego or external reality. In response to this signal, the ego creates a defense mechanism to prevent unacceptable thoughts or feelings from escaping into consciousness. 2) Behavior theory This theory suggests that anxiety is a conditioned response in accordance with the presence of a specific stimulus from the environment. Individuals receive certain stimuli as unwelcome stimuli, causing anxiety. After it happens repeatedly, it eventually becomes a habit to avoid the stimulus. Theory represents the accumulation of knowledge about mechanisms of action (mediators) and moderators of change as well as a priori assumptions about what human behavior is, and what effect it has on it (12). 3) Existential theory This theory provides models of generalized anxiety, in which there is no identifiable stimulus for chronic feelings of anxiety. The core concept of this theory is that people experience the feeling of living in a purposeless world. Anxiety is a response to the perception of emptiness. There are also biological theories about the causes of anxiety. Existential concerns such as death, responsibility, futility, and isolation are not only hallmarks of existential psychotherapy but also frequently encountered by Cognitive Behavioral therapists (13). This theory relates to the autonomic nervous system and neurotransmitters. Stimulation of the Saini et al MEDICAL AND HEALTH SCIENCE JOURNAL 2023 FEBRUARY VOL.07 (01) Page 49 of 53 autonomic nervous system causes certain symptoms such as: cardiovascular (eg. tachycardia), muscular (eg. headache), gastrointestinal (eg. diarrhea), and respiratory (eg. tachypnea). There are three neurotransmitters associated with anxiety: norepinephrine, serotonin, and gamma-aminobutyric acid (GABA) (2). In addition to the above theories, there are also several other causes, such as: 1) Failure to complete developmental tasks Adolescents have developmental tasks that must be completed. The main psychological dangers of adolescence are generally caused by failure to make the psychological transition to maturity which is an important developmental task of adolescence. Common danger signs of adolescent inability to self-adjust include irresponsible behavior that appears in the behavior of ignoring lessons to have fun and getting social support, aggressive behavior and overly hot teen, feelings of insecurity that cause adolescents to comply with group standards, flight response if you are away from familiar surroundings, feelings of giving up, fantasizing too much to compensate for the dissatisfaction gained from everyday life, regressing to previous levels of behavior in order to be liked and noticed, and using defense mechanisms such as rationalization, projection, fantasizing, and displacement. 2) Past experience Disorders that occur during adolescence cannot be separated from childhood experiences, for example: trauma, psychological violence (swearing, demeaning, defaming, and insulting), psychological neglect (neglecting the right to express feelings, lack of feelings of being loved, and being cared for), physical violence, physical neglect, and sexual violence. Anxiety disorders that occur in adolescents are mostly caused by the experience of psychological violence and psychological neglect in childhood. Anxiety disorders are associated with negative experiences in daily life, which cannot be explained by co- morbidities alone (14). 3) Bereavement 'Attachment' is an important concept in psychiatry because it encompasses patterns of social relationships and subsequent interactions with others. Short or long separations and events of loss will cause a disturbance. 4) Physical Condition Adolescence is characterized by rapid physical growth. Physical condition is seen as an important matter. When physical conditions do not match expectations, dissatisfaction, anxiety, and low self- esteem will arise. A study in Indonesia (2016), stated that the higher the level of health anxiety, the higher the level of subjective somatic symptoms. Symptoms of a minor illness can cause disproportionate health anxiety if the person exaggerates the seriousness of the sensation (15). 5) Family Problem Conflict in the family is often caused by disharmony between parents and children and family background problems. Parents who are too busy, are dictatorial, old-fashioned, and have favoritism towards their children will make the relationship in the family disharmonious. 6) Interpersonal conflict Adolescence is a period in which adolescents must be able to mature relationships with their peers, so selective friendships begin to emerge which sometimes triggers quarrels. Adolescence is also a time to get to know the opposite sex and love. Problems related to love are complicated problems. Women's sense of self that is more dependent on relationships with others makes them more susceptible to social anxiety. However, all individuals in East Asian cultures generally have a higher degree of social construction of interdependence (16). 7) Fear of failure and losing oneself For adolescents, the opinion of the people around them is very important. Constant criticism or failure with a mismatch of praise or success will cause a sense of inferiority and even loss of self-esteem. Someone who has low self-esteem or loses self- esteem will feel used to failure and sometimes even develop self-sabotaging behavior. Adolescence is clearly a critical period for the process of maturation of the neurobiological system which is the basis of emotions and behavior. Adolescence marks a period of great susceptibility to developing disorganized levels of social anxiety (17). 8) Living environment An adaptation is needed to live in a new environment (boarding house, dormitory, relation house). The inability to adapt will cause anxiety. Several factors were found to be negatively or Saini et al MEDICAL AND HEALTH SCIENCE JOURNAL 2023 FEBRUARY VOL.07 (01) Page 50 of 53 positively related to depression. Perception of health is negatively related to depression, while smoking behavior, smoking cessation, and acute illness are positively related to depression (18). 9) School environment School environmental conditions such as intense competition, academic demands / high-grade standards, piling assignments, school rules, teaching-learning methods, majors, and student- teacher relations as well as student-to-student relationships are very important in determining the success of adolescents in school. The inability to adapt to the school environment will cause anxiety. Usually, to meet academic demands, teenagers will take various courses, sometimes even not having time to do things they enjoy/hobbies. This will further worsen their adaptability. 10) Social environment Adolescents spend more time outside the home with their peers, so the influence of their social environment on attitudes, speech, interests, appearance, and behavior is greater than other environmental influences (2). When associated with the above theories, what is experienced by the patient is closely related to several theories include: 1) Past experience. The patient had an experience where she felt unloved by his parents because she had been left behind since the patient was in the womb. During the developmental period, the patient also has difficulty developing trust in others and peaks in the time of interview when she experienced her physical complaints, the patient also does not want this to be known by her partner because there is an excessive fear of losing her partner due to her mental disorder. 2) Bereavement Closely related to the event of separation both short, long, and loss events. Now, the patient is still hurting from her breakup with her partner and feels like losing something that had healed the wounds of being abandoned by his father and mother. The patient feels fear of another abandonment by others. 3) Interpersonal conflict The patient does not stop blaming herself because according to the patient, his father and mother work for her well-being. Likewise, the case of a partner who left her was because she could not be a good partner. In addition, the patient also said that her friendship environment did not help the patient to forget her problems. They always make her feel guilty. A study states that there is a relationship between the characteristics of depression, anxiety, and stress with gender, age, marital status, and income in adults during a pandemic. This shows that men, younger age, single status, and low income have higher depression, anxiety, and stress characteristic scales(19). 4) The patient's fear of failure and loss of self- esteem has long been present, but during elementary to high school, it did not show because the patient was quite intelligent, but during college, the patient felt that he was the stupidest person. Therefore, it is related to the patient's job as a content creator which is always required to provide what the client wants. The patient keeps on accepting criticism and trying to pursue the target for client fulfillment. This resulted in fear of failure to fulfill client expectations. Everyone has a different reaction to stress, and some of the symptoms that appear are not the same. Common anxiety symptoms include: 1) Palpitation 2) Pain or tenderness in the chest 3) Shortness of breath 4) Excessive sweating 5) Changes in sexual arousal or interest in sexual activity 6) Sleep disturbance 7) Trembling 8) Hands or limbs become cold and sweaty 9) Anxiety accompanied by depression leads to suicidal ideation 10) Health problems such as frequent headaches (migraines). Some common anxiety disorders include: A. Generalized anxiety disorder – often feeling anxious or worried. B. Panic disorder – having panic attacks regularly, often for no apparent reason. C. Post-traumatic stress disorder (PTSD) – experiencing anxiety problems after experiencing a very stressful or frightening event. D. Social anxiety disorder - fear or fear of social situations E. Obsessive-compulsive disorder (OCD) – repeating unpleasant thoughts (obsessions) and Saini et al MEDICAL AND HEALTH SCIENCE JOURNAL 2023 FEBRUARY VOL.07 (01) Page 51 of 53 engaging in certain routines (compulsions) to relieve anxiety. F. Phobia - an overwhelming fear of a particular object, place, situation, or feeling (10). The symptoms of anxiety above can be grouped into four symptoms: a. Somatic disorders Tremors, fluctuating body temperature, seizures, sweating, palpitations, nausea, diarrhea, dry mouth, decreased libido, shortness of breath, and difficulty swallowing b. Cognitive impairment Difficulty concentrating, confusion, fear of losing control, excessive vigilance, and thoughts of a great catastrophe. c. Behavioral disorders Expression of fear, irritability, aggression, immobilization, and withdrawal from society. d. Perceptual disturbance depersonalization and derealization (2). Several symptoms that appeared in the patient were caused by the patient's anxiety. Lately, the patient was occupied with the thought of many targets that must be achieved as a content creator because of the client's demands. The patient still felt symptoms such as shortness of breath, stomach disturbances, chest feels heavy, cold and sweaty hands even though she has taken medication regularly. This condition makes the patient develop difficulty sleeping until she can't sleep (sleep disturbances occur). Evidence-based psychological treatments (cognitive-behavioral therapy; CBT) for this disorder have been developed and investigated, and in recent years a promising low-intensity CBT intervention version has been proposed that offers a way to improve access to evidence-based care. There is some evidence of the effectiveness of pharmacological treatments for anxiety disorders in children and adolescents, but their routine prescription is discouraged because of fears of potential harm (20). Pharmacological treatment of generalized anxiety disorder is carried out by administering antidepressants (Selective Serotonin Reuptake Inhibitors (SSRIs), and anti-anxiety (benzodiazepines (BZD) and non-BZDs (buspirone)). Antidepressants and BZD can inhibit LC thereby reducing norepinephrine activity, while BZD modulates receptors GABA to increase its activity. Antidepressants can selectively inhibit serotonin reuptake, while buspirone is a partial serotonin receptor agonist. In addition to pharmacological therapy, management of therapy for generalized anxiety disorder can also be carried out by non- pharmacological therapy. Non-pharmacological therapy includes psychoeducation, short-term counseling, stress management, psychotherapy, meditation, exercise, or Cognitive Behavioral Therapy (CBT).(21) Most adolescents with anxiety disorders tend to discuss their problems with friends and family to relieve anxiety, whereas some do not seek help because they can deal with their own anxiety disorders, they think they don't really need help, they feel no one cares about them, their problems, and the lack of supporting health facilities in the youth environment. Adolescents in East Java are advised to consult their mental health problems with experts to find relevant solutions.(22) CONCLUSION Based on PPDGJ III and DSM-5, the patient was diagnosed with generalized anxiety disorder. Based on the theories that cause anxiety, the causes of this patient's anxiety are included in several theories including past experiences, loss events, interpersonal conflicts, fear of failure, and self- esteem. 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