I.

General Condition
Awareness : Composmentis
Attention : good
Attitude : Cooperative
Inisiative : good
Motoric behaviour : active
Facial expression : poor
Speech and verbal : speak fluently
and clear
Physical contact : could be done,
natural, and long-time

II. Spesific condition

A. Natural State of Feeling
1. Afective condition : hipothym
2. Emotion Living
a. Stability : labil
b. Control : controlled
c. ech unecht : echt
d. einfuhlung : adequate
e. deep-shallow : deep
f. differentiation scale : narrow
g. emotion flow: fast

B. Intelectual Funnction
Memory

(amnesia)
: good
Concentration
: adequat
Orientation
(time, spatial, personal, situation)
: undisturbed
general knowledge
: good

discriminative

insight
: good
alleged level of intelegency :
cannot
evaluated
discriminative judgment
: good
intelectual deterioration
:
absent

C. Perseption and sensation anomaly

a. illution
: absent
b.halutination
- acustic : absent
- visual
: absent
- olfatorik
: absent
- tactil
: absent

D. Way of Thinking
1. Psikomobilitas : fast
2. Thingking process
a. clear and sharp : clear but not sharp
b. Sirkumstansial : absent
Inkoherrent

: absent
Sperrung : absent
Hemmung
: absent
Flight of ideas : absent
Verbigerasi Persevarative ( Persevaratich )
absent

3. Contents
a. Central pattern : absent
Phobia : absent
Obsess : absent
Dellusion
: absent
Suspicion
: absent
Confabulation : absent
Animosity/revenge : absent
Inferior feeling : absent
Much/less
: less
Guilty feeling: absent
Hippochondria : absent
Others : -

E. Instinctual impulse disorders

Abulia
: absent
Stupor
: absent
Raptus / impulsivitas : absent
excitement state : absent
sexual deviation : absent
Echophraxia
: absent
Vagabondage
: absent
Piromani
: absent
Mannerisme
: absent
Others
:F. Overt anxiety
: yes
G. Relation to reality : good (behavior,

VI. Multiaxial Evaluation

Axis I. Clinical Syndrome

General condition: cooperative, active, poor,

speaking fluently and clear, psychic contact could
be done for long duration of time, attention intact.
Specific condition
Natural state of feeling : hypothym, labil, good
controlling, echt, adequate einfuhlung, deep, narrow
differentiation scale, fast emotion flow.
Intellectual condition : memorizing abililty good,
concentrarion ability good, orientation undisturbed,
general knowledge good, discriminative insight
good, allegged level of intelegency cannot
evaluated, discriminative judgment good,
intellectual deterioration absent.

 Sensation

and perception disorder:

illusion and hallucination absent.
Process of Thinking: fast, clear but not
sharp, circumstancial, incoherrent,
Sperrung, Hemmung, flight of ideas,
verbigeration, central pattern, phobia,
delusion absent, suspicion absent,
confabulation, animosity and revenge,
inferior feeling, less, guilty feeling,
hypochondria are absent.

Instinctual

encouragement:
abulia absent, stupor absent,
raptus absent, excitement state
absent, sexual deviation absent,
echophraxia absent,
vagabondage absent, pyromania
absent, mannerisme absent.
Anxiety: yes
Relation to reality: good
(behavior, feeling, thinking)

Axis II. Personality

disorder and mental
retardation

Axis III. General

Medical Condition

Axis IV. Psychosocial

and environment

Axis V. Global
Assessment of
Functioning

There is no personality disorder and

mental retardation

No history of head trauma, malaria,

typhoid, and other disease which needs
hospitalization. No history of alcohol
and drugs consumption.

No diagnosis

80-71: Symptoms temporary and

can be overcome, mild disability in
social, work and school.

MULTIAXIAL DIAGNOSIS
Axis I : F 41.1 General Anxiety
Disorder
Axis II : No diagnosis
Axis III : No diagnosis
Axis IV : No diagnosis
Axis V : GAF 80-71

DIFFERENTIAL DIAGNOSIS

F 41 Panic disorder
THERAPY

Pharmacotherapy :
Alprazolam 1 x tab@ 0,5 mg
Amitriptyline 1 x tab @ 25 mg

Psychoteraphy
- Patient
Supportif psycotherapy
Psychoeducation
- Family : Psychoeducation about
Patient disorder
Teraphy

PROGNOSIS

Assesment

Good

Onset

Adult

Relaps

Often

Diagnosis

General Anxiety disorder

Family Support

Good

Medicine Respons

Baik

Marriage

Married

Economy Condition

Moderete

Obedience to take medicine

Dicipline

Trigger

Overthinking about children

Genetic

Nothing

Penyakit lain/ gangguan lain

Nothing

Bad

Quo

ad vitam : dubia ad bonam

Quo ad fungsionam : dubia ad bonam
Quo ad sanationam : dubia ad bonam

The thing that can make good prognosis :

onset,
family support,
medicine respons, marriage,
economy condition,
obedience to take medicine,
genetic, and
no other disease and disorder.
The thing that can increase bad prognosis :
relaps and the trigger.

XII. CASE ANALYSES

.

Patients
chief
complains
:
anxiety
(everyday
in more than six month),
Medical palpitation, headache, get a trouble for
History sleep and easy to cry
No drunk and using drug history.

Normal blood pressure (120/80 mmHg).

Physical Cardiovascular, respiratory,

gastrointestinal, and neurologic
Examinati examination shows no abnormalities.

on

Diagnosy

PPGDJ III
1. anxiety symptoms
showed everyday for
several weeks until
month and its free
floating.
2. Tremor, palpitation
and headache
3. No drunk or using
drug history

General anxiety
disorders.

DSM IV
1. Anxiety symptomps
showed during a day
and everyday and
thats happen more 6
month.
2. Difficult to controlled
the anxiety.
3. Anxiety can be
meaningful to make
clinical disorder.

General anxiety
disorders.

General Anxiety Disorder

Pharmacotheraphy
Alprazolam 1 x tab @ 2 mg, Amitriptyline 1
x tab @ 25 mg.

Psychotherapy :
1. Patient : Supportif psycotherapy &
Psychoeducation
II. Family : Psychoeducation about : Patient
disorder and Teraphy