Anxiety and Phobic Disorders: Clinical Guidelines

List of Abbreviations

IAT – Integrative Anxiety Test

ICD – International Classification of Diseases

RCTs – Randomized Controlled Trials

SSRIs – Selective Serotonin Reuptake Inhibitors

AFR – Anxiety and Phobic Disorders

LCE – level of confidence of evidence

GRS – grade of recommendation strength

BAI – The Beck Anxiety Inventory

CGI – Clinical Global Impression Scale

COPE – Coping Orientation to Problems Experienced

HARS – The Hamilton Anxiety Rating Scale

IIP – Inventory of Interpersonal Problems

ISTA – Ich Struktur Test nach G. Ammon (G. Ammon, I. Burbiel)

LSI – Life Style Index

MDMQ – Melbourne Decision Making Questionnaire

MMPI – Minnesota Multiphasic Personality Inventory

MPS – Multidimensional Perfectionism Scale

SCL-90-R – Symptom Check List-90-Revised

ShARS – Sheehan Anxiety Scale

STAI – State-Trait Anxiety Inventory

** – drug included in the National List of Vital Essential Drugs

# – this disease or disorder is not specified in the instructions for use

TCAs – tricyclic antidepressants (N06AA non-selective monoamine reuptake inhibitors)

Terms and Definitions

Psychopharmacotherapy is the use of psychotropic drugs in the treatment of mental disorders.

Psychotherapy – a system of therapeutic intervention on the human psyche, and through the psyche and by means of it, on the entire human body.

Anxiety is a negatively valenced emotion expressing a feeling of uncertainty, anticipation of negative events, and hard-to-define premonitions. Unlike the causes of fear, the causes of anxiety are usually not consciously recognized, but it prevents a person from engaging in potentially harmful behavior or prompts them to take action to increase the likelihood of a favorable outcome.

Phobia is a symptom consisting of irrational, uncontrollable fear or a persistent experience of excessive anxiety in certain situations or in the presence (anticipation) of a certain known object; a characteristic feature is also its object-directedness, the focus of fear on a particular object, its plot-driven and fabulized nature.

Isolated (specific) phobia is an obsessive fear of specific, strictly limited situations or objects.

Agoraphobia originates from the Greek root "agora", meaning a place of assembly, structure, marketplace; the second part, "phobos", means fear, terror. This term was first used by Westphal (1871) to describe "the inability to walk down certain streets or squares, or the ability to do so only in a state of severe anxiety." Currently, agoraphobia is used to denote the fear of going outside, into squares, public places, stores, transport—going "outwards".

Social phobia is a pronounced fear of one or more situations involving actions in the presence of other people and/or fear of anticipated negative evaluation (criticism, ridicule) by others in relatively small groups, rather than crowds. This condition differs from ordinary "shyness" in that it causes severe impairment in the subject's life. Social situations that provoke anxiety are avoided by the patient or endured with distress, while they understand that their fear is excessive and irrational. Avoidant behavior and anxiety lead to significant functional deterioration. In ICD-10, this diagnosis is coded as F40.1.

Anxiousness (Trait anxiety) is a stable individual psychological feature reflecting an individual's predisposition to experience anxiety in various situations, including the expectation of an unfavorable outcome in relatively neutral situations that contain no real threat.

Shyness is a psychological phenomenon lacking a precise definition, representing anxiety and discomfort in social situations, particularly in cases involving evaluation by authority figures, discomfort and inhibition in interpersonal situations, and the fear of negative evaluation.

Social anxiety is anxiety triggered by various types of social interaction situations. The concept of social anxiety encompasses a range of phenomena—from the mildest form, shyness, to a clinical disorder, social phobia or avoidant personality disorder.

Social anxiety disorder is a disorder based on the fear of negative evaluation by others; a term planned to replace the ICD-10 diagnosis of "social phobia" in ICD-11 (code 6B04).

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Anxiety and phobic disorders (AFRs) are a group of disorders characterized in their clinical picture by object-specific anxiety and fear of certain situations or objects (external to the subject) that pose no real danger. As a result, the patient tries to avoid such situations or is forced, finding themselves in them, to overcome the feeling of fear. As a rule, experiencing fear in the provoking environment or situation, patients try to resist it, weaken its intensity, and look for ways to combat it using various techniques and distractions. [1,2,3,4,161].

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Risk factors for the development of AFRs include:

- psychological factors: general negative affectivity, a tendency to experience negative emotions, and anxiety sensitivity. Personality traits such as timidity, fearfulness, high impressionability, and indecisiveness manifest from early childhood.

There is evidence of a link between social phobias and biological characteristics, temperament, cognitive style, parenting style, and peer relationship experiences; in a reference group, such individuals felt uncomfortable and unprotected, and were distinguished by hypersensitivity, tearfulness, and poor tolerance for criticism, jokes, and ridicule, especially from significant others, as well as adverse life events and cultural characteristics. High levels of social anxiety are associated with a lack of social skills and negative self-esteem [2,5,6,7].

- social factors: the presence of psychotraumatic events in childhood (emotional deprivation or the death of a parent). In addition, patients with anxiety and phobic disorders report both a lack of emotional warmth and hyperprotection in their family history. Studies have shown a correlation between the type of child-parent attachment and social anxiety. The type of attachment formed in early childhood determines the basic sense of security, influences the perception of interpersonal relationships and the formation of the individual's core beliefs about themselves and the surrounding world, and creates prerequisites for mistrust and anxiety. Ambivalent attachment results from the unpredictable, contradictory behavior of a significant caregiver. Avoidant attachment is formed as a result of the ignoring of the child's emotional needs and personal qualities in relationships with the caregiver. For example, parents react with indignation when the child "fails to meet their expectations" or take offense at their children's refusals.

A high level of social anxiety is also associated with an overprotective, intrusive parenting style. Furthermore, its development is facilitated by adverse social experiences, including intimidation, rejection, bullying, and neglect. Patients with social anxiety tend to engage in so-called "safety" behavior—they focus on predicting potential harm and constantly avoiding potentially unpleasant situations, which in turn hinders anxiety reduction. "Behavioral inhibition" is one of the early indicators of social anxiety, which may subsequently evolve into specific personality traits (low extraversion and high neuroticism) and the development of maladaptive cognitive schemas [2,6,7,8,9,10].

- the cognitive model is based on the information-processing model of the human psyche and the study of dysfunctional beliefs among patients with anxiety and phobic disorders regarding themselves, the surrounding world, and the behavior of other people. Meanwhile, "safe" avoidance behavior prevents patients with phobias from questioning their distorted perceptions [2,6,8,11].

- genetic and physiological factors: anxiety and phobic disorders are polygenic multifactorial diseases; extensive research is underway on genetic polymorphisms (multiple genetic variants) responsible for the manifestation of these disorders. The influence of genetic factors varies for specific phobias, averaging 35–45%, while for agoraphobia—which is the most heritable form of phobia—this figure reaches 61%. Twin studies have shown that social anxiety has a hereditary basis shared with neuroticism and extraversion, though genetic studies have not yet demonstrated conclusive risk variants. Modern neurobiological studies indicate the involvement of certain basal ganglia within the amygdala-hippocampal complex, the superior temporal sulcus, the prefrontal and parietal cortices, and the dorsal striatum. Alterations in brain white matter volume within specific tracts responsible for cognitive functions and affective regulation are considered potential biomarkers. However, most studies emphasize that the development of anxiety and phobic disorders involves a combination of genetic and environmental factors, the specific role and ratio of which are not always straightforward [13,14,15,16,17,18,19,20,21].

- there are studies confirming the role of inflammation in the development of these disorders, noting elevated concentrations of inflammatory markers, including cytokines and C-reactive protein, which are associated with the activation of the stress response in central and peripheral immune cells and the release of cytokines [22].

- social anxiety is additionally characterized by an elevated cortisol response and lower testosterone levels. These neuroendocrine changes are linked to the functioning of connections within the amygdala-prefrontal cortex circuit [10].

- the specific pathogenesis of anxiety and phobic disorders is currently insufficiently studied and is considered similar to that of panic disorder, with a high proportion of conditioned reflex mechanisms determining the manifestation of symptoms in specific situations.

1.3 Epidemiology of the Disease or Condition

Anxiety and phobic disorders occur with a frequency of 5–12%. Most phobic disorders, except for social phobias, are more common in women. The female-to-male ratio is 4:1 for agoraphobia; 1:1 for social phobias; and 2:1 for specific (isolated) phobias. The lifetime prevalence (% of the population) is 1.6% for agoraphobia; 3–13% for social phobias; and 7.2–11.3% for specific (isolated) phobias. Data on the prevalence of anxiety and phobic disorders in Russia are lacking, but the diagnosis is established significantly less frequently than in foreign countries [252,253]. Among specific phobias, fears of heights and animals are the most common. Although specific phobias often onset in childhood, their frequency peaks in middle and older age. Phobias persist for several years or even decades in 10–30% of cases and serve as a predictor for the onset of other disorders, including anxiety, mood, and substance use disorders [4,23,24,25,26,27,28,29].

1.4 Features of Coding the Disease or Condition

F40 – Phobic anxiety disorders

F40.0 – Agoraphobia

.00 – Without panic disorder

.01 – With panic disorder

F40.1 – Social phobias

F40.2 – Specific (isolated) phobias

F40.8 – Other phobic anxiety disorders

F40.9 – Phobic anxiety disorder, unspecified

1.5 Classification of the disease or condition

Classification of anxiety and phobic disorders

1. Agoraphobia

2. Social phobias

3. Specific phobias

   1) Animals (e.g., fear of insects, dogs)

   2) Natural environmental forces (e.g., fear of storms, water)

   3) Blood, injections, injuries (e.g., needles, medical procedures)

   4) Situations (e.g., fear of airplanes, elevators, enclosed spaces)

   5) Other types of phobias [29,30,31,32]

1.6 Clinical presentation of the disease or condition

The clinical picture of anxiety and phobic disorders is dominated by the fear of specific situations or objects (external to the subject) that pose no real danger. As a result, the patient avoids such situations or endures them while overcoming a sense of fear.

Phobic anxiety:

– physiologically and behaviorally does not differ from other types of anxiety;

– can vary in intensity from mild discomfort to terror;

– is not alleviated by the knowledge that other people do not consider the situation to be dangerous or threatening;

– even the thought of entering a phobic situation typically triggers anticipatory anxiety [1,2,29,33,34,35].

Anticipatory anxiety and thoughts of encountering a phobic stimulus can lead to sleep disturbances, where patients develop difficulties initiating and maintaining sleep due to anxious rumination; these disturbances may worsen as the time of confrontation with the frightening situation approaches.

Agoraphobia is among the most frequent types of anxiety and phobic disorders. It is a fairly well-defined group of phobias that includes the fear of being left without assistance away from home, in crowds, in public places, alone, while commuting, in transport, the metro, trains, buses, airplanes, on bridges, etc. Despite variations in anxiety intensity and avoidance behavior severity, this is the most disabling of the phobic disorders, sometimes confining patients to their homes because they are unable to go outside due to their fears. In some cases, they manage to do so only when accompanied by close individuals whom they consider reliable in situations where help might be needed. In individuals with a predominant hysteroid personality trait, symptoms may be demonstrative and manipulative, compelling those around them to fulfill the patient's desires and whims. In agoraphobia, anxiety is restricted to the following situations: crowds, public places, traveling away from home, and traveling alone. Avoidance of phobic situations is pronounced, up to the point of complete refusal. The patient is fully aware of the content of their fear; attempts to force oneself through it usually either yield no results or are endured with great discomfort. In some cases, the patient adopts compromise behaviors, such as choosing a taxi instead of public transport when travel is necessary, or trying to buy groceries in small shops rather than large supermarkets when experiencing a fear of public places [1,2,29,36,37,38,39,40,41,161].

Another frequent form of anxiety and phobic disorder is social phobia, which represents a form of impaired interpersonal interaction. Conventionally, two forms of social anxiety are distinguished:

1. Generalized social phobia – the patient fears all social situations; society exerts a pervasive influence, serving as a constant source of anxious tension and self-doubt. It has a severe course and is complicated to treat.

2. Specific (isolated) social phobia – in this case, the patient reacts only to specific social situations. It has a milder course and responds quite successfully to treatment.

The fear of attention and negative evaluation from other people is in most cases irrational and often forms in adolescence, when negative feedback and comments from others are perceived particularly acutely. The patient is afraid of being subjected to mockery, criticism, condemnation, being humiliated, failing to meet others' expectations, or facing a negative reaction from others if they end up in the spotlight, and is fixated on this. Even in situations where other people are objectively not paying attention to them, it seems that eyes are fixed on them and the evaluation of their behavior or appearance is exclusively negative, contemptuous, or mocking. The individual experiences anxiety in social situations when two conditions coincide: 1) high motivation to make a desired (specific), usually positive, impression on others; 2) the presence of doubts that this is achievable. The main situations that actualize sociophobic experiences in patients with social phobias include: the need to maintain a conversation; public speaking; participation in theatrical performances and amateur talent shows; making acquaintances; meetings with the opposite sex; playing in an orchestra, singing in a choir; communicating with superiors; receiving visitors; eating at home in the presence of other people, even family members; performing work in the presence of outsiders; a medical examination; using a public toilet, etc. The main themes of sociophobic experiences in these patients are the following: "people think I am bad," "my appearance seems unattractive to others," "people think I am stupid," "I look, walk, and talk in a ridiculous and absurd way," "I will not meet the expectations of people who are important to me," "I am an uninteresting person," "I am unhelpful, irresponsible, dependent, anxious, weak, uninitiated [sic - uninitiative]," "nothing will work out for me," etc. Anxiety in a patient with social phobias can reach such an intensity level that it triggers secondary cognitive and somatic symptoms. The most common secondary cognitive manifestations of sociophobic symptomatology include: "emptiness" in the head; inability to concentrate; the feeling that thoughts cannot be controlled, "jumble in the head"; "obsessive replay" of the situation; excessive demands on oneself; focus on controlling one's behavior.

This disorder occurs with equal frequency in men and women. In addition to the fear of simply being the center of attention, there is often a fear of behaving inappropriately, failing to cope with a task, doing something funny or stupid, saying something absurd, or being ridiculed. Against the background of anxious experiences, autonomic symptoms arise that further exacerbate the patient's condition. Frequent symptoms include flushing (which can form a specific fear of blushing in public – erythrophobia), blushing of the neck, hand tremors, voice trembling, sweating, a feeling of faintness, and dizziness. The patient feels that those around them notice in detail and negatively evaluate all their somatovegetative manifestations of anxiety, which increases anxiety, creating a vicious circle. Symptoms also include borborygmus, nausea, fear of vomiting, urges or fear of urination or defecation. The fear can be isolated (e.g., only fear of eating in the presence of other people, public speaking, meetings with a certain circle of acquaintances) or generalized, encompassing almost all social situations outside the family circle. Obviously, in this case, there is a significant impairment of social functioning, interfering with building personal relationships, communicating, studying, and engaging in professional activity. In the most severe manifestations, social isolation develops. The onset of anxiety symptoms occurs only or predominantly in situations that cause fear, or when thinking about them. Before a trigger situation or social interaction, patients with social phobia imagine in detail everything they think might happen. Following this, anxiety arises, their mind is filled with images of past failures, negative self-perceptions, and presentiments of possible failures and rejections. Such reflections lead to the avoidance of interpersonal interaction situations. If a social event nevertheless occurs, patients with social phobia analyze its smallest details, focusing on those that confirm the negative schema; thus, the event is always perceived more negatively than it actually was. Typically, the development of social phobia is preceded by a low level of social skills, low self-esteem, and fear of criticism. In the medical history of such patients, one can often find unsuccessful experiences of relationships in the school team, peer rejection, and teasing by teachers. In parent families, the attitude towards the child also contributes to the formation of low self-image [1,2,29,42,43,44,45,46,47,48,49,50,51,52,53,54,161,162].

Specific (isolated) phobias are distinguished as the third major group of anxiety-phobic disorders—psychopathological disorders characterized by the presence of fear regarding a specific object or action. Often, the fear is associated with a specific object that was the cause of real or imagined danger in the past. An isolated situation acts as a triggering mechanism in a specific phobia; entering it can cause terror and panic, just like in agoraphobia or social phobia. At the moment of fear, vivid autonomic manifestations are noted. Accordingly, pronounced avoidance of such situations develops. It should be noted that the fear is irrational and does not correspond to the real danger of the object or situation. Significant emotional distress is determined due to the symptoms or the desire to avoid situations, while insight is present, along with the understanding that the phobic experiences are excessive or unreasonable. The fear of phobic objects does not show a tendency to fluctuations in intensity, in contrast to agoraphobia. Objects of fear sometimes appear in anxious, nightmare dreams. A distinction is made between the fear of an object (e.g., an animal, an insect) and the fear of a specific situation (e.g., heights, thunder, darkness, enclosed spaces, vomiting, urination or defecation, eating certain foods, dental treatment, the sight of blood or injury) with the need to avoid them. Nosophobia also belongs to this same diagnostic category—the fear of falling ill, most commonly cardiac arrest, cancer, stroke, radiation sickness, sexually transmitted infections, acquired immunodeficiency syndrome, hepatitis C, and others. Specific (isolated) phobias most often arise in childhood or adolescence and can persist for decades. The decrease in adaptation depends on how easily the patient can avoid the phobic situation. For a reliable diagnosis, it is necessary to make sure that the psychological or autonomic symptoms are primary manifestations of anxiety, rather than secondary to other symptoms such as delusions or obsessions; anxiety must be limited to a specific object or situation; the phobic situation is avoided whenever possible [1,2,29,55,56,57,58,59,60,61,62,63].

Adopting the criterion that a phobic object or situation is external to the subject implies that many fears of having a disease (nosophobia) or deformity (dysmorphophobia) are now classified under heading F45.2 (hypochondriacal disorder). However, if the fear of illness arises and recurs mainly upon possible contact with infection or contamination, or is simply a fear of medical procedures (injections, surgeries, etc.) or medical facilities (dental offices, hospitals, etc.), heading F40.0 (usually F40.2, specific (isolated) phobias) will be appropriate in this case [1,2,29,32].

Often, phobic anxiety and depression occur simultaneously. The decision to make two diagnoses (anxiety-phobic disorder and depressive episode) or only one is made taking into account the degree of predominance of one disorder over the other, as well as the sequence of their onset. If the criteria for a depressive disorder existed even before the phobic symptoms first appeared, then the former disorder is diagnosed as the primary one [1,2,29,32].

Panic disorders, depressive disorders, eating disorders, obsessive-compulsive disorders, and suicidal behavior frequently accompany anxiety-phobic disorders as comorbid conditions [1,2,29,64,65,66,67,68,69,70,71]. Due to the frequent use of alcohol and sedative drugs for anxiolytic purposes, patients with anxiety-phobic disorders may abuse them, and the risk of developing alcohol and sedative dependence increases. [1,2,29,64,67,68,161,162,163]

2. Diagnostics, medical indications and contraindications for diagnostic methods

Diagnostic criteria for the diagnosis/condition (ICD-10 research diagnostic criteria):

F40 Phobic anxiety disorders:

F40.0 Agoraphobia.

A. Distinct and consistently occurring fear of at least two of the following situations, or avoidance of them:

1. crowds;

2. public places;

3. traveling alone;

4. moving outside the home.

B. Since the onset of the disorder, at least two symptoms of anxiety must be present simultaneously in frightening situations in at least one instance, and one of these symptoms must belong to items 1–4 of the following list:

Autonomic symptoms:

1. pounding or accelerated heart rate;

2. sweating;

3. trembling or shaking;

4. dry mouth (not due to medication or dehydration);

Symptoms related to the body:

5. breathing difficulties;

6. feeling of choking;

7. chest discomfort or pain;

8. nausea or abdominal distress (e.g., burning in the stomach);

Mental status symptoms:

9. feeling dizzy, unsteady, or faint;

10. feeling that objects are not real (derealization), or that one's own self has drifted away or "is not really here" (depersonalization);

11. fear of losing control, going crazy, or impending death;

12. fear of dying;

General symptoms:

13. hot flashes or chills;

14. numbness or tingling sensations.

C. Significant emotional distress due to the avoidance of the situation or anxiety symptoms, while the patient is aware that they are excessive or unreasonable.

D. Anxiety symptoms occurring only or predominantly in situations that provoke fear or when thinking about them.

E. Most commonly used exclusion criteria. The fear or avoidance of situations (criterion A) is not accounted for by delusions, hallucinations, or other disorders such as organic mental disorders (F00-F09), schizophrenia and related disorders (F20-F29), mood (affective) disorders (F30-F39), or obsessive-compulsive disorder (F42), and does not stem from cultural beliefs and traditions.

The presence or absence of panic disorder (F41.0) in most cases of agoraphobia can be additionally specified using the fifth character:

F40.00 without panic disorder

F40.01 with panic disorder

Options for assessing severity

Severity in F40.00 can be assessed by indicating the degree of avoidance of frightening situations,

taking into account specific cultural conditions. Severity in F40.01 can

be assessed by counting panic attacks.

F40.1 Social phobias

A. One of the following features must be present:

1. marked fear of being the center of attention or fear of behaving in a way that will cause embarrassment or humiliation;

2. marked avoidance of being the center of attention or of situations involving fear of acting in a way that could cause embarrassment or humiliation.

These fears manifest in social situations such as eating or speaking in public places, casual encounters with acquaintances in public, or being in small groups (e.g., at parties, meetings, or in a classroom).

B. At some time during the course of the disorder, there must be at least two symptoms of anxiety in feared situations, as defined by criterion B in F40, and in addition, one of the following symptoms:

1. blushing or trembling;

2. fear of vomiting;

3. urgency or fear of micturition or defecation.

C. Significant emotional distress due to the symptoms or avoidance behavior, and recognition that the anxiety is excessive or unreasonable.

D. Anxiety symptoms are restricted to or predominate in situations that provoke fear or when thinking about them.

E. Most commonly used exclusion criteria. The symptoms listed in criteria A and B are not due to delusions, hallucinations, or other disorders such as organic mental disorders (F00-F09), schizophrenia and related disorders (F20-F29), (affective) mood disorders (F30-F39), or obsessive-compulsive disorder (F42.), and are not secondary to cultural beliefs and traditions.

F40.2 Specific (isolated) phobias.

A. Any of the following features:

1) marked fear of specific objects or situations not falling under agoraphobia (F40.0) or social phobia (F40.1),

2) marked avoidance of specific objects or situations not falling under agoraphobia (F40.0) or social phobia (F40.1).

Among the most common are fears of animals, birds, insects, heights, thunderstorms, flying, small enclosed spaces, the sight of blood or wounds, injections, dentists, and hospitals.

B. Anxiety symptoms in feared situations, as defined by criterion B in F40.0, must manifest at some point since the onset of the disorder.

C. Significant emotional distress due to the symptoms or avoidance behavior, and recognition that they are excessive or unreasonable.

D. Anxiety symptoms are restricted to situations that provoke fear or when thinking about them.

If desired, specific phobias may be subdivided as follows:

– animal type (e.g., fear of insects, dogs);

– natural environment type (e.g., fear of storms, water);

– blood-injection-injury type;

– situational type (e.g., fear of elevators, tunnels);

– other type.

2.1 Complaints and Anamnesis

Main complaints: anxiety, phobias, fear of death (thanatophobia), fear of cardiac arrest, fear of stroke, fear of a specific disease, fear of going crazy (losing self-control), fear of open spaces, fear of becoming helpless, fear in social situations, fear of interpersonal communication, fear of attention from others, isolated fears in specific situations, somatovegetative disorders, and restrictive (avoidant) behavior [6,14].

• All patients with phobic and anxiety disorders are recommended to undergo an examination (consultation) by a psychiatrist/psychotherapist with a detailed clinical and psychopathological assessment (including history taking, evaluation of suicide risk, severity of phobic manifestations, and restrictive behavior) [1,2,3,4,29,36,40,41,161].

GCR CLOCE 4Grade of Recommendation C (Level of Evidence 4)

• During the interview of all patients presenting with complaints of anxiety and fears as part of the initial examination by a psychiatrist (B01.035.001) / psychotherapist (B01.034.001), it is recommended to identify the connection between anxiety attacks and specific situations that do not pose a real danger, in order to verify the diagnosis [1,2,3,4,29,36,40,41,161].

GCR CLOCE 4Grade of Recommendation C (Level of Evidence 4)

• When taking a history and conducting a clinical interview as part of the initial examination by a psychiatrist (B01.035.001) / psychotherapist (B01.034.001) in all patients with complaints of anxiety and fear related to specific objects or situations, it is recommended to establish the presence of restrictive and avoidant behavior associated with specific fears in order to verify the diagnosis, assess the severity of the condition, and determine the treatment strategy [1,2,3,4,29,40,41,161].

GCR CLOCE 4Grade of Recommendation C (Level of Evidence 4)

• During the interview of all patients with anxiety and fear related to specific objects or situations, as part of the initial examination by a psychiatrist (B01.035.001) / psychotherapist (B01.034.001), it is recommended to single out complaints related to autonomic manifestations accompanying panic attacks, in order to assess the condition and select therapy [1,2,3,4,29,40,41,43,161].

GCR CLOCE 4Grade of Recommendation C (Level of Evidence 4)

• During the interview of all patients with anxiety and fear related to specific objects or situations, as part of the initial examination by a psychiatrist (B01.035.001) / psychotherapist (B01.034.001), it is recommended to assess the severity of anticipatory anxiety in order to evaluate the condition and select therapy [1,2,3,4,29,40,41,43,161].

GCR CLOCE 4Grade of Recommendation C (Level of Evidence 4)

• During the interview and history taking of all patients with anxiety and fear related to specific objects or situations, as part of the initial examination by a psychiatrist (B01.035.001) / psychotherapist (B01.034.001), it is recommended to identify the presence of potential comorbid mental disorders (including post-traumatic stress disorder, depressive and bipolar disorders, etc.) for differential diagnosis and consideration when selecting therapy [1,2,3,4,29,40,41,43,161].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

• During the interview and history taking of all patients with anxiety and fear related to specific objects or situations, as part of the initial examination by a psychiatrist (B01.035.001) / psychotherapist (B01.034.001), it is recommended to assess the level of alcohol and psychoactive substance use to evaluate the risk of dependence development and for consideration when selecting therapy [1,2,29,43,161,162,163].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

• When taking a history in all patients with phobic and anxiety disorders, as part of the initial examination by a psychiatrist (B01.035.001) / psychotherapist (B01.034.001), it is recommended to assess suicide risk in order to determine the type and scope of psychiatric care [1,2,3,4,29,40,41,43].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

• In all patients with phobic and anxiety disorders, it is recommended to perform differential diagnosis with the following conditions [1,2,3,29,67,68,69,70,71, 161,162,163]:

– obsessive-compulsive disorder;

– post-traumatic stress disorder;

– generalized anxiety disorder;

– hypochondriacal disorder;

– mood disorders (depressive episode, recurrent depressive disorder, bipolar disorder, dysthymia);

– somatoform disorders;

– schizophrenia, schizotypal disorder;

– specific personality disorders (histrionic, obsessive-compulsive, anxious, emotionally unstable);

– epilepsy;

– residual organic brain diseases;

– organic brain diseases;

– alcohol dependence;

– psychoactive substance dependence;

– hypothalamic disorder;

– thyroid diseases.

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

2.2 Physical Examination

• All patients presenting with complaints of anxiety and fear related to specific objects or situations are recommended to undergo a standard physical and neurological examination (B01.023.001 initial examination (inspection, consultation) by a neurologist) to rule out somatic and neurological causes of autonomic symptoms [1,2,3,4,29,40,41,43,58].

GCR CLOCE 4Grade of Recommendation C (Level of Evidence 4)

• In all patients with complaints of anxiety and fear related to specific objects or situations, the physical examination is recommended to include an external inspection, measurement of height and body weight, assessment of physical development (A01.30.024 drawing up a conclusion on physical development), and evaluation of the integrity of the patient's skin, in order to rule out somatic diseases, detect signs of self-harm (taking into account their prescription), and assess somatic status [1,2,3,4,29,40,41,43,58].

GCR CLOCE 4Grade of Recommendation C (Level of Evidence 4)

• All patients with complaints of anxiety and fear related to specific objects or situations are recommended to undergo a set of tests to diagnose thyroid function disorders (B03.058.001): therapeutic palpation (A01.30.011) and exophthalmometry (A02.26.022) [1,2,3,4,29,40,41,57].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

• All patients with complaints of anxiety and fear related to specific objects or situations are recommended to have their pulse examined (A02.12.001) and blood pressure measured on peripheral arteries in the supine position (after resting for 5 minutes) and standing position (3 minutes after standing up) (A02.12.002) to evaluate autonomic manifestations and somatic status [1,2,3,4,29,40,41,59].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

2.3 Laboratory Diagnostics

Currently, there are no laboratory diagnostic methods for phobic and anxiety disorders. The main purpose of laboratory tests – is to rule out somatic diseases that may present with symptoms similar to phobic and anxiety disorders.

• All patients presenting with complaints of anxiety and fear related to specific objects or situations are recommended to undergo a general (clinical) urinalysis, a complete blood count (CBC) with differential, including total hemoglobin (A09.05.003) and hematocrit evaluation, red blood cell count (A12.05.118), white blood cell count (A12.05.119), platelet count (A12.05.120), and erythrocyte sedimentation rate (ESR) (A12.05.001) as part of the initial evaluation, upon hospital admission, and during follow-up monitoring to determine the degree of disease activity and assess for organ and systemic involvement [1,2,3,29].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

• All patients presenting with complaints of anxiety and fear related to specific objects or situations are recommended to undergo a general general-medical blood chemistry panel (including potassium (A09.05.031), sodium (A09.05.030), chloride (A09.05.034), glucose (A09.05.023), creatinine (A09.05.020), total protein (A09.05.010), urea (A09.05.017), uric acid (A09.05.018), total bilirubin (A09.05.021), direct and indirect bilirubin (A09.05.022), aspartate aminotransferase (A09.05.041) and alanine aminotransferase (A09.05.042) activity, and C-reactive protein (A09.05.009)) as part of the initial evaluation, upon hospital admission, and during follow-up monitoring to assess renal and hepatic function and rule out inflammation [1,2,3,29].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

• All patients presenting with complaints of anxiety and fear related to specific objects or situations are recommended to undergo testing for hepatitis B surface antigen (HBsAg) in blood, antibodies to hepatitis C virus (HCV) in blood, antibodies to Treponema pallidum in blood, and human immunodeficiency virus HIV-1/HIV-2 antibodies (IgM, IgG) in blood, as part of the initial evaluation, upon hospital admission, and subsequently every 12 months to rule out association with HIV infection, hepatitis, or syphilis [1,2,3,29].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

• All patients presenting with complaints of anxiety and fear related to specific objects or situations are recommended to undergo blood testing for thyroid function: total triiodothyronine (T3), free triiodothyronine (fT3), total thyroxine (T4), free thyroxine (fT4), and thyroid-stimulating hormone (TSH), to rule out thyroid pathology [1,2,3,29].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

Comment: Thyroid hormone screening is recommended for patients being evaluated for the first time who have never undergone this test before, or if there are clinical or anamnestic indications.

Comment: The primary objective of laboratory evaluations is to rule out somatic disorders that may present with symptoms similar to specific phobias and anxiety disorders

2.4 Instrumental Diagnostics

At present, there are no instrumental diagnostic methods specifically for specific phobias and anxiety disorders.

• In patients presenting with complaints of anxiety and fear related to specific objects or situations, in whom history-taking, physical and neurological examination, and laboratory results do not allow paroxysmal conditions to be ruled out with a high degree of certainty, it is recommended to perform electroencephalography (EEG) to assess brain bioelectric potentials and rule out such pathology [1,2,3,29].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

• In patients presenting with complaints of anxiety and fear related to specific objects or situations with a history of syncopal episodes, and in individuals in whom history-taking, physical and neurological examination, and laboratory results do not allow cerebrovascular disorders to be ruled out with a high degree of certainty, it is recommended to perform transcranial duplex scanning of arteries and veins to rule out this pathology [1,2,3,29].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

• In patients presenting with complaints of anxiety and fear related to specific objects or situations who have a history of traumatic brain injury, suspected brain tumors, headaches, or in whom history-taking, physical and neurological examination, and laboratory results do not allow organic brain damage to be ruled out with a high degree of certainty, it is recommended to perform magnetic resonance imaging (MRI) of the brain to rule out such pathology [1,2,3,29].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

• All patients presenting with complaints of anxiety and fear related to specific objects or situations are recommended to undergo electrocardiography (A05.10.006 ECG recording) to assess somatic status, objectify autonomic cardiovascular dysfunction (palpitations, sensation of skipped beats or discomfort in the heart area), and rule out cardiovascular disease [1,2,3,29].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

2.5 Other Procedures

Specialized psychological assessment includes: 1) clinical-psychological psychodiagnostic examination (A13.29.003.001) and 2) pathopsychological experimental-psychological (psychodiagnostic) evaluation (B03.035.004).

Specific phobias and anxiety disorders are conditions in whose pathogenesis and clinical (clinical-psychopathological and clinical-psychological) manifestations psychological factors play a major role, and psychotherapy is an effective treatment method. Based on the biopsychosocial concept of mental disorders, it is important to include medical psychologists in multidisciplinary teams to participate in diagnostic and therapeutic measures in order to determine the patient's individual psychological characteristics that are preserved or impaired due to the illness, identify targets for psychotherapeutic intervention, and objectify the dynamics of therapeutic measures [1,2,3,34].

At the same time, one of the most critical components of a medical psychologist's involvement in providing medical care to patients with specific phobias and anxiety disorders is psychological assessment. All core types, methods, and techniques accepted both in psychological assessment in general and in its applied clinical branch—known as "medical psychodiagnostics" or "clinical psychological assessment"—are utilized. In accordance with the basic theoretical principles of psychological assessment, clinical practice employs both clinical-psychological (expert) methods (clinical interview, observation, conversation, analysis of activity products, etc.) and experimental-psychological methods. Questionnaire methods rely heavily on the self-assessment nature of the data obtained and have certain limitations regarding the objectivity of such data. On the other hand, they more fully reflect the individual psychological characteristics of the personality itself, their preservation or alteration in the context of illness, and reveal a wide range of the subject's relationships, attitudes, coping styles, and other clinically significant personality traits and person-environment interactions. Such data must be evaluated within a personalized approach under the biopsychosocial paradigm of modern anthropocentric and clinical sciences. Furthermore, clinical methods are organically integrated into experimental-psychological testing procedures and are used directly while the subject performs tasks and test batteries. A distinctive feature of applying clinical and experimental-psychological methods in addressing psychological assessment tasks is the consideration and analysis of specific features caused by the patient's illness-altered mental and psychological status.

Thus, when conducting a psychodiagnostic examination of a patient with specific phobias and anxiety disorders within a clinical-psychological psychodiagnostic evaluation, the following are applied:

1. Clinical rating scales;

2. Clinical-psychological and experimental-psychological methods and techniques (non-standardized patho- and neuropsychological tasks, standardized psychometric test batteries).

• Patients presenting with complaints of anxiety and fear related to specific objects or situations who require psychometric and/or experimental-psychological evaluation of the severity of clinical manifestations and individual psychological characteristics are recommended to undergo a clinical-psychological psychodiagnostic examination (A13.29.003.001) and/or pathopsychological experimental-psychological (psychodiagnostic) evaluation (B03.035.004) for differential diagnosis and assessment of condition dynamics [29,164,165].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

• For patients with complaints of anxiety and fear associated with specific objects or situations who need psychometric assessment of clinical manifestations and/or experimental psychological assessment of clinical manifestations and individual psychological characteristics, it is recommended to use psychometric scales, symptom and test questionnaires to assess the level of anxiety and its dynamics, personality traits, characteristics of interpersonal interaction, etc. [1,2,3,29,72,165].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

Comments: In patients with anxiety and phobic disorders, it is necessary to use psychometric scales, symptom and test questionnaires for screening and assessing the level of anxiety, phobic experiences and their dynamics, personality traits, characteristics of interpersonal interaction, etc., the selection and scope of which are determined individually depending on the clinical picture of the disease, diagnostic and therapeutic tasks: The Hamilton Anxiety Rating Scale (HARS) (Appendix G1); to assess the severity of clinical manifestations, the Symptom Check List-90-Revised (SCL-90-R) (Appendix G2) can be used; Integrative Anxiety Test (IAT) (Appendix G3); State-Trait Anxiety Inventory (STAI) (Appendix G4); The Beck Anxiety Inventory (BAI) (Appendix G5); Sheehan Anxiety Scale (ShARS) (Appendix G6) [1,2,3,29,72].

The presented methods are psychometric (symptom) questionnaires that allow an objective assessment of the nature and severity of clinical symptoms, their dynamics, and the effect of ongoing treatment.

A more comprehensive psychological diagnosis is carried out by a medical psychologist depending on specific diagnostic tasks or to determine the targets of psychotherapeutic intervention. The attending physician prescribes a clinical and psychological psychodiagnostic examination and/or a pathopsychological experimental-psychological (psychodiagnostic) study. The choice of psychological diagnostic methods and techniques falls within the competence of the medical psychologist, provided that the data requested by the attending physician are presented in the text of the psychological report. The choice of techniques for conducting an experimental-psychological diagnosis of the patient is carried out by the medical psychologist individually depending on the tasks regarding a specific patient. Various scales adapted and validated depending on the objectives of the study may be used [165,166,167,168,169]. The methods proposed below are used optionally and the list of possible methods for conducting an experimental-psychological examination is not limited to them.

If a rapid assessment of status dynamics is required, the Clinical Global Impressions Scale (CGI) is used.

The most frequently used methods for studying the psychological structure of personality: Minnesota Multiphasic Personality Inventory – Standardized Clinical Personality Questionnaire (MMPI) (adapted by L.N. Sobchik et al. (1970) – full MMPI version) (Appendix G7) [2,29,151]; Ich Struktur Test nach G. Ammon – G. Ammon's Ego-Structure Test (ISTA) (Appendix G8) [2,29,152].

The most frequently used methods for studying individual psychological personality traits: Method for determining the level of subjective control (LSC) (Appendix G9) [2,29,153]; Personal Beliefs Test (Kassinove H., Berger A., 1984) (Appendix G10) [2,29,154]

The most frequently used methods for psychological diagnosis of mental maladaptation risk factors: Life Style Index (LSI) (Appendix G11) [2,29,155]; Ways of Coping Questionnaire by R. Lazarus (WCQ, Folkman S., Lazarus R., 1988) (Appendix G12) [2,29,156]; Melbourne Decision Making Questionnaire (MDMQ) (Appendix G13) [2,29,157].

The most frequently used methods for psychological diagnosis of the system of significant relations: KON-2006 Neurotic Personality Questionnaire (Aleksandrowicz J. et al., 2006) (Appendix G14) [2,29,158]. To study treatment adherence, the following method is used: Russian Universal Quantitative Treatment Adherence Questionnaire (KOP-25) (Appendix G15) [2,29,159].

To diagnose the level of social anxiety, measure the fear of negative evaluation, and assess their impact on social adaptation, the following methods are used: Liebowitz Social Anxiety Scale (LSAS) (Appendix G16); Brief Fear of Negative Evaluation Scale (BFNE) (Appendix G17) [245,246,247,248].

To identify gelotophobia (the fear of being laughed at, becoming an object of ridicule), the Gelotophobia Questionnaire (GELOPH-15) (Appendix G18) [250,251].

To study the severity of social phobias, the following methods are used:

Psychological diagnostics is performed by a medical psychologist according to the following algorithm [165,166,167,168,169]:

Stage 1 – Clinical and psychological examination aimed at establishing a trusting relationship, assessing the patient's current emotional state and behavior, and their attitude towards the examination and treatment. Methods: observation, conversation, interview, life history analysis. The psychologist notes and subsequently records in the report based on the results of the experimental-psychological study (EPS): availability for contact, attitude towards the examination, understanding of instructions, interest in testing results, loudness and speed of speech, facial expressions, general emotional background, pace of psychomotor reactions, behavioral characteristics during the examination, and personal traits demonstrated by the patient.

Stage 2 – Experimental psychological study (EPS). The objectives of the experimental psychological examination are: differential diagnosis of disorders of the patient's mental activity;

– analysis of the structure and establishment of the degree of disorders of mental processes, states, and personality properties;

– determination of the level of development of psychological adaptive potential, the degree of preservation of the patient's psychological adaptive mechanisms and resources;

– assessment of the dynamics of mental processes as a result of the treatment provided;

– resolution of expert tasks.

During the experimental psychological study, higher mental (cognitive) functions, the patient's personal and emotional sphere are studied, and a qualified expert assessment of the identified disorders is performed. Based on the results of the EPS, an expert report is drawn up (Appendix G21), and expert psychologist recommendations are given, which must be taken into account by specialist physicians in the treatment process [166,167,168].

The total duration of the psychological diagnostic procedure in a psychiatric clinic is 3–5 hours and includes 2 types: 1) Clinical and psychological psychodiagnostic examination (A13.29.003.001) and 2) Pathopsychological experimental-psychological (psychodiagnostic) study (B03.035.004) [77,165,170,171].

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

Data from modern scientific research show the priority application of psychotherapy in terms of efficacy in the treatment of anxiety and phobic disorders. Some studies confirm the effectiveness of both psychopharmacotherapy (drugs from the groups of selective serotonin reuptake inhibitors, benzodiazepine derivatives, anxiolytics, antipsychotics, etc.) and psychotherapy (cognitive-behavioral, dynamic, relaxation, etc.). In the treatment of anxiety and phobic disorders, psychotherapy is a priority method of treatment and often plays a leading role. Regarding anxiety and phobic disorders, there are fewer studies on the efficacy of pharmacological drugs than regarding panic disorder and generalized anxiety disorder. The data obtained regarding many drugs show their moderate efficacy in anxiety and phobic disorders. There are studies showing the efficacy of the combined use of psychopharmacotherapy and psychotherapy.

Regarding specific phobias, as in psychiatry in general, there are relatively few intra-nosological studies on the efficacy of treatment for individual specific phobias. This is quite understandable, since the list of phobic stimuli is constantly growing; in clinical guidelines we have listed the most common ones, however, it should be borne in mind that the Russian Federation is a multinational and multiconfessional state, therefore, culturally specific phobias may occur in certain regions. Modern research highlights the important role of cultural sensitivity of mental health specialists for the delivery of quality care [272,273,274,275,276,277].

On the other hand, despite the wide variety of triggers, the key factor in the manifestation of specific phobic disorders is their subjective interpretation as intolerable by patients, with the subsequent development of similar anxiety-phobic symptoms. Therefore, the results of RCTs obtained regarding the treatment of social phobia can be used in the treatment of similar conditions, especially considering that the target of therapeutic interventions is not the phobic trigger, but the patient's reaction to it.

The choice of therapy strategy and the ratio of psychopharmacotherapy and psychotherapy depend on clinical symptom manifestations, the treatment stage, personality traits, patient attitudes and expectations, current resources, and organizational capabilities, and should be flexibly evaluated using a personalized approach in each specific case. There are both indications and contraindications for psychopharmacological and psychotherapeutic treatment. These are primarily related to the patient's condition, side effects, and organizational conditions [72,73,74,75,76,77,78,79,80,81,82,83,84,85,86,87].

• For all patients with anxiety-phobic disorders, the use of psychopharmacotherapy and/or psychotherapy is recommended in order to relieve symptoms [72,73,74,75,76,77,78,79,80,81,82,83,84,85,86,87,161].

GCR ALEL 1Grade of Recommendation A (Level of Evidence 1).

Comments: Regarding anxiety-phobic disorders, psychotherapy is a higher priority in treatment tactics selection. The advantages of psychotherapy include the absence of somatic side effects and, according to some studies, a longer-lasting effect and greater efficacy for anxiety-phobic disorders. Disadvantages include higher cost, the need for weekly visits, and the critical importance of personal motivation and patient engagement in the treatment process. Psychopharmacotherapy requires less financial and time investment, but is often insufficiently effective, causes side effects, and symptom relapse is possible upon discontinuation.

3.1 Psychopharmacotherapy

Since RCTs organized to evaluate the efficacy of drugs in treating anxiety-phobic disorders were conducted for the most common variants of phobias, without taking into account the specifics of the clinical course, there are certain difficulties in applying their results when implementing a personalized approach in medicine. Most studies relate to social phobias. If panic attacks are present in agoraphobia, the physician can be guided by the clinical guidelines for "Panic Disorder" when prescribing medications. There are practically no RCTs investigating the efficacy of pharmacotherapy in specific phobias.

For patients with anxiety-phobic disorders who have no indications for hospitalization in a medical facility, outpatient psychotherapy and/or pharmacotherapy is preferred.

• For patients with social phobias and agoraphobia who have frequent and/or intense clinical manifestations, as first-line therapy, it is recommended to prescribe antidepressants from the selective serotonin reuptake inhibitor group or #venlafaxine in order to reduce the level of anxiety, emotional tension, and the intensity of phobic experiences leading to avoidance of phobic situations [76,77,173,174,175,176,177,178,179,180,181,182,183,184,185,186,187,188,189,190,191,192,193,194,195,196,197,198,199,200,201,261,262,263].

GCR ALEL 1Grade of Recommendation A (Level of Evidence 1)

Comments: The high efficacy of SSRI antidepressants or #venlafaxine in social phobias and agoraphobia with panic disorder is confirmed by numerous publications. Although separate studies on the use of antidepressants in patients with agoraphobia without panic disorder have apparently not been conducted, many RCTs and meta-analyses in agoraphobia with panic disorder specifically evaluated the effect of drugs on agoraphobic symptoms, which provides grounds to use the obtained results to determine the treatment strategy for agoraphobias in general [261,262,263].

The range of effective antidepressant dosages for relieving panic and agoraphobic symptoms is: paroxetine** 20-40 mg/day [76,77,173,174,175,176,177,178,179,180], escitalopram 10-20 mg/day [76,77,181,182,183,184,185]; sertraline** 50-200 mg/day [76,77,186,187,188,189], #fluvoxamine 100-300 mg/day [76,77,190,191,192,193,194,195]; or from the selective serotonin and norepinephrine reuptake inhibitor group (N06AX Other antidepressants): #venlafaxine 75-225 mg/day [76,77,197,198,199,200,201]. The efficacy of #citalopram in doses of 20-40 mg/day has been confirmed in only one RCT [77,196,262]. Paroxetine** in doses of 20-40 mg/day demonstrated efficacy in specific (simple) phobias in a double-blind, placebo-controlled study [180].

• For patients with specific phobias who have frequent and/or intense clinical manifestations, it is recommended to prescribe antidepressants from the selective serotonin reuptake inhibitor group: escitalopram at a dose of 10-20 mg or paroxetine** at a dose of 20 mg in order to reduce the level of anxiety, emotional tension, and the intensity of phobic experiences [180,264].

GCR BLOCE 2Grade of Recommendation B (Level of Evidence 2)

Comments: The use of antidepressants in specific (simple) phobias is generally insufficiently studied. The literature reveals information on only two small RCTs using paroxetine** and escitalopram. In addition, some publications described clinical cases of #fluoxetine** use [180,264].

Comments: The antidepressant treatment option should be chosen individually for each patient, taking into account the psychotropic and somatotropic action of the drug, possible adverse events, the patient's mental and somatic status, and the clinical characteristics of the disease, including the frequency and intensity of phobic experiences. Therapy with these drugs starts with minimal dosages and is gradually titrated to therapeutic ones; the anxiolytic effect of antidepressants develops individually within 2-8 weeks. Therefore, at the first stage of treatment, it is advisable to use a combination with benzodiazepine derivatives, especially with pronounced intensity of phobic experiences.

The advantages of antidepressants include a favorable efficacy-tolerability-safety profile, the possibility of once-daily administration, and the presence of a long-term therapeutic effect; disadvantages include a delayed effect, a possible anxiogenic effect at the start of administration, the need for dosage titration, and a negative impact on sexual function;

When prescribing pharmacotherapy, the physician relies primarily on information about the proven efficacy of the drug, its tolerability profile, as well as the physician's own clinical experience and qualification [72,160].

• For patients with anxiety-phobic disorders who have frequent and/or intense clinical manifestations, as well as in cases of rare encounters with the phobic stimulus (e.g., flying by plane several times a year in aerophobia, annual health check-ups in fear of injections), it is recommended to prescribe benzodiazepine derivatives: #clonazepam** 0.5-3 mg/day, #alprazolam 0.5-0.75 mg/day in order to reduce the level of anxiety, emotional tension, and the intensity of phobic experiences [72,73,76,77,78,80,81,91,92,202,203,204,278,279].

GCR BLOCE 2Grade of Recommendation B (Level of Evidence 2)

Comments: These drugs are prescribed in a short course and can be first-line medications due to their immediate action; the effect is achieved after the very first dose of the drug in cases of short-term distress, for example, in aero- or dentophobia. They can also be prescribed episodically when necessary to cope with a specific upcoming situation.

The advantages of benzodiazepine derivatives include a rapid onset of action, good tolerability, a wide therapeutic window ensuring safety in overdose; a thorough addiction history must be obtained prior to prescribing this group of drugs. It is inadvisable to prescribe them to patients with substance use disorders or those at risk of developing substance dependence [205]. It is also not recommended to prescribe them to elderly patients due to an increased risk of coordination disorders and falls. Attention should be paid to patient compliance, as some patients are prone to exceeding recommended dosages. Benzodiazepine derivatives can be habit-forming and cause a withdrawal syndrome upon sudden cessation of therapy. Therefore, the duration of their use should be limited to 2-3 weeks. When prescribed in combination therapy with antidepressants, they are preferably administered during the first weeks of treatment until antidepressants take full effect, and then tapered off. Longer-term therapy with benzodiazepines is possible in cases of resistance to other types of therapy. The most common adverse events include sedation, dizziness, impaired coordination, concentration difficulties, memory impairment, and the development of dependence and tolerance. There are no evidentiary studies on the efficacy of bromdihydrochlorphenylbenzodiazepine**. However, in Russian medical practice, it is traditionally used to treat anxiety disorders and manage phobic attacks at a dosage of 1-3 mg/day (0.5-1 mg 2-3 times a day) [73,205].

When prescribing benzodiazepine derivatives, the half-life should be taken into account when deciding on the dosing frequency and prevention of accumulation effects (bromdihydrochlorphenylbenzodiazepine** is not recommended to be prescribed more than 1-2 times a day due to its long half-life; #alprazolam should be prescribed at least 3 times a day due to its relatively short half-life).

• For patients with phobic and anxiety disorders who experience insufficient efficacy or poor tolerability of selective serotonin reuptake inhibitors or #venlafaxine, it is recommended to use #pregabalin** at a dose of 150-600 mg/day to reduce anxiety levels, emotional tension, and the intensity of phobic experiences [95,207,208,209].

GCR ALOCE 2Grade of Recommendation A (Level of Evidence 2)

Comments: The anxiolytic effect of #pregabalin**, its impact on psychological, somatic, and autonomic components of anxiety, as well as its good tolerability and high safety profile, have been thoroughly studied in several evidentiary studies and confirmed in meta-analyses. The anxiolytic effect of #pregabalin** is achieved within the first week of administration.

Unlike most antidepressants, #pregabalin** does not inhibit cytochrome P450 enzymes, has no drug-drug interactions with other medications (e.g., warfarin**), and can be used in patients with phobic and anxiety disorders and chronic somatic diseases.

#Pregabalin** should not be prescribed to patients prone to developing dependence or those who already have various forms of substance dependence. Such patients exhibit a cross-dependence phenomenon and a more rapid increase in tolerance. A thorough addiction history of the patient is recommended to minimize the risk of dependence formation

• For patients with specific phobias who encounter the phobic stimulus infrequently, it is recommended to use a single dose of #pregabalin** of 150 mg to reduce anxiety levels, emotional tension, and the intensity of phobic experiences [207].

GPR BLEL 2Grade of Recommendation B (Level of Evidence 2).

• For patients with phobic and anxiety disorders presenting with frequent and/or intense clinical manifestations, it is recommended to prescribe the antiepileptic drug #gabapentin at 900-3600 mg/day to reduce anxiety and the intensity of phobic experiences [2,73,76,78,79,80,81,140,141,142,143,144,145,146,147,148,149,150].

LoR CLE 3Level of Recommendation C (Level of Evidence 3)

• For patients with phobic and anxiety disorders presenting with frequent and/or intense clinical manifestations who have an insufficient response to therapy with selective serotonin reuptake inhibitors or #venlafaxine, it is recommended to use therapy with other antidepressants: #mirtazapine 30-45 mg/day [206,257,258]

GPR BLEL 2Grade of Recommendation B (Level of Evidence 2)

or #agomelatine** 25-50 mg/day [137]

GPR CLoE 4Grade of Recommendation C (Level of Evidence 4).

• For patients with phobic and anxiety disorders presenting with frequent and/or intense clinical manifestations who have an insufficient response to antidepressant monotherapy, antipsychotic drugs are recommended as an adjunct or standalone treatment to reduce the intensity of cenesthetic sensations, psychovegetative disorders, and hypochondriacal fixation, to lower anxiety and the intensity of phobic experiences, and to target the cognitive component of anxiety and phobic disorders [72,73,76,77,81,93,138,139].

GPR ALEL 1Grade of Recommendation A (Level of Evidence 1)

Comments: In domestic medical practice, these drugs are traditionally used to treat anxiety disorders when monotherapy fails, when the cenesthetic component is prominent (which is often observed in nosophobias), in protracted courses of phobic and anxiety disorders, and in the presence of overvalued hypochondriacal fixation and pronounced psychovegetative disorders [72,73,76,77,81,93,138,139]. Among antipsychotic drugs, those most frequently prescribed for phobic and anxiety disorders are: #sulpiride** 50-400 mg/day, #quetiapine** 25-300 mg/day. Two small pilot RCTs demonstrated the efficacy of #quetiapine** monotherapy ranging from 50 to 400 mg (titration schedule: first 3 days – 25 mg twice a day, then: 4 days – 50 mg twice a day, second week – 100 mg twice a day, third week – 150 mg twice a day, fourth week – 200 mg twice a day) [265,266]. Adjunctive therapy with antipsychotic drugs must be carried out under careful medical supervision due to the development of adverse side effects (dizziness, orthostatic hypotension, drowsiness, weight gain, akathisia and other extrapyramidal symptoms, hyperprolactinemia, etc.). Due to the aforementioned side effects, second-generation antipsychotic drugs are preferred for the patient, as there is a high risk of poor compliance and refusal of psychopharmacotherapy

• For patients with phobic and anxiety disorders presenting with frequent and/or intense clinical manifestations, considering the delayed onset of action of antidepressants, it is recommended to use other anxiolytic drugs for a rapid effect on anxiety and phobic symptoms [211,282].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

Comments: in medical practice, #hydroxyzine** is used at 25-100 mg/day. Scientific literature contains data supporting both the efficacy and inefficacy of this drug group in treating phobic and anxiety disorders. Therefore, it is advisable to use these drugs in combination with antidepressants on a continuous course, but they can also be taken independently as a course of treatment or episodically in cases of infrequent exposure to a phobic stimulus (for instance, flying several times a year for aerophobia, or annual medical check-ups for fear of injections).

• For patients with social phobias where the phobic situation involves a sexual context (coital phobia), feelings of shame, failure, or humiliation during sexual interactions, it is recommended to use #trazodone therapy at 50-200 mg/day to reduce anxiety and normalize sexual functioning [259,280].

GCR BLOCE 2Grade of Recommendation B (Level of Evidence 2)

Comments: when prescribing #trazodone, the possibility of developing priapism as a side effect must be taken into account. Priapism is a pathologically prolonged erection of the penis (or clitoris) unrelated to sexual stimulation. The causes of priapism are impaired blood circulation in the corpora cavernosa of the penis (or clitoris) due to blood stasis, increased blood viscosity, and a shift in blood pH toward acidity. Prolonged priapism is associated with a high risk of necrosis and gangrene of the penis (or clitoris), requiring surgical intervention. In cases of priapism, #trazodone must be discontinued immediately [267]

• For patients with phobic and anxiety disorders presenting with frequent and/or intense clinical manifestations, it is recommended to carry out pharmacotherapy for a duration of 6 to 12 months after achieving a therapeutic effect from the applied therapy in order to stabilize the effect and prevent relapses. In cases of mild or infrequent phobic manifestations, medications can be used in courses or episodically in accordance with indications [2,72,73,76,78,79,80,81].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

• In all patients with anxiety and phobic disorders receiving psychotropic drugs, it is recommended to regularly assess the following potential side effects of psychopharmacotherapy: sedation, somnolence, sluggishness, urinary retention, constipation or diarrhea, nausea, headaches, dizziness, coordination impairment, attention deficit, memory impairment, development of drug dependence and tolerance, sexual dysfunctions, etc. It is necessary to evaluate the side effects of specifically prescribed medications in order to assess the benefit-tolerability ratio [2,72,73,76,78,79,80,81,251].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

Comments: at the same time, adequate dosages and strictly indicated drug prescriptions significantly reduce the risk of side effects.

• In all patients with anxiety and phobic disorders receiving psychotropic drugs, it is recommended to assess the efficacy and tolerability of therapy, which is carried out on days 7, 14, and 28 of psychopharmacotherapy and subsequently once every 4 weeks until the end of the treatment course in order to timely adjust the ongoing treatment. In case of intolerance or insufficient efficacy, dosage adjustment or drug switching is performed [1,2,72,73,76,78,79,80,81,283].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

• In all patients with anxiety and phobic disorders undergoing inpatient treatment with monitoring and care provided by nursing staff, it is recommended to conduct an examination (consultation) by a psychiatrist/psychotherapist to assess the efficacy of the treatment course [1,2,72,73,76,78,79,80,81,283].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

• In all patients with anxiety and phobic disorders upon the planned completion of long-term antidepressant therapy or forced premature discontinuation (due to poor compliance or tolerability), a gradual dose reduction is recommended to prevent withdrawal symptoms [212,213,214].

GOR BLOE 2Grade of Recommendation – B (Level of Evidence – 2).

Comments: The dose reduction period may take several days, weeks, or even months, depending on the dose, duration of treatment, pharmacological properties of the drug, and the patient's condition. The necessity of gradual dose reduction is due to the potential development of antidepressant discontinuation syndrome (ADS) [215,216]. These symptoms are usually transient and resolve quickly upon re-administration of the antidepressant. The risk of their development is higher when the anticholinergic properties of the drug are more pronounced, the dosage used is higher, and the duration of administration is longer. Among newer generation antidepressants, ADS is most characteristic of #venlafaxine and SSRIs with a short half-life (e.g., paroxetine**), and less characteristic of #fluoxetine** [212]. Abrupt discontinuation of TCAs (N06AA Non-selective monoamine reuptake inhibitors) can trigger a cholinergic "rebound" phenomenon (flu-like state, myalgia, cramping abdominal pain). To avoid ADS or manage its manifestations in case of a decision to discontinue antidepressants, the following algorithm for the prevention and management of patients with antidepressant discontinuation syndrome is proposed (see Appendix B2).

Drugs from the selective serotonin reuptake inhibitor group have proven their efficacy in preventing relapses during long-term therapy, but the quality of evidence was moderate.

The duration of maintenance therapy in anxiety and phobic disorders is determined based on the patient's individual characteristics, the dynamics of the clinical picture, and concomitant treatment. Patients receiving long-term therapy require regular medical supervision to detect early signs of relapse and timely manage them, monitor potential side effects of therapy and adherence to the medication regimen, conduct psychotherapeutic measures aimed at motivating the patient to continue treatment, and provide assistance in the event of traumatic psychological situations.

3.2 Psychotherapy

Psychotherapy is a proven effective method for treating neurotic disorders, including anxiety and phobic disorders. A number of studies have demonstrated greater efficacy of psychotherapy in agoraphobia, social phobia, and specific (isolated) phobias. It should be noted that, overall, psychopharmacotherapy provides faster improvement and requires less effort from the patient, as well as less time and economic costs, but symptoms may recur when medications are discontinued. Psychotherapy, especially when psychological mechanisms of formation and maintenance of anxiety and phobic disorders play a significant role, provides a higher quality effect and more stable remission. Considering the leading role of psychological factors in the development of anxiety and phobic disorders, psychotherapy is of primary importance for their treatment compared to psychopharmacotherapy. In some cases, the optimal approach is a combination of psychopharmacotherapy and psychotherapy, as this best aligns with the modern biopsychosocial concept of mental disorders and allows for the implementation of personalized medicine principles, thereby increasing the efficacy of therapeutic interventions. There is evidence-based research regarding a number of psychotherapeutic methods. For certain anxiety and phobic disorders, psychotherapy is more effective than psychopharmacotherapy. However, it must be remembered that the design of evidence-based research in psychotherapy is quite complex and clinical practice differs from scientific experiments in many parameters. The large body of literature showing the efficacy of cognitive behavioral therapy is likely related to the ability to reproduce specific techniques within research settings rather than an unconditional priority of this method for patients with anxiety and phobic disorders. Other psychotherapeutic methods currently having a smaller evidence base may be no less—and in certain cases potentially more—effective than cognitive behavioral therapy. In the treatment of anxiety and phobic disorders, methods utilizing virtual reality technologies for exposure generation and building tolerance to phobic stimuli have proven effective [1,2,74,77,96, 97,98,99,100,101,102,103,104,161,162,217].

Contraindications and limitations to psychotherapeutic treatment [2,74,96,98,99,161]:

1) patients with a fear of self-disclosure and a predominance of denial among their psychological defense mechanisms;

2) patients with insufficient motivation for change and obvious secondary gain from illness;

3) patients with low interpersonal sensitivity;

4) patients who are unable to attend psychotherapy sessions regularly;

5) patients who will not participate in the process of active verbalization and listening in individual and group psychotherapy;

6) patients whose characterological features prevent them from working constructively in individual and group psychotherapy and benefiting from this work (who constantly act out their emotions externally as a defense reaction rather than observing their psychological state; or patients with severe negativism or rigidity).

• In the treatment of all patients with anxiety-phobic disorders, it is recommended to use various types of psychotherapy, either alone or in combination with psychopharmacotherapy, in order to achieve a more effective and sustained reduction in anxiety and intensity of phobic experiences, to learn relaxation, correct irrational attitudes, raise awareness of deep mechanisms and contradictions, and overcome avoidant behavior [2,74,96,97,98,99,100,101,102,161,162,217].

GCR ALEL 1Grade of Recommendation A (Level of Evidence 1)

• For all patients with anxiety-phobic disorders, except for those with intellectual disability, it is recommended to conduct 10–15 sessions of cognitive-behavioral psychotherapy in order to reduce anxiety levels and the intensity of phobic experiences, correct irrational attitudes, and overcome avoidant behavior [2,74,97,105,106,107,108,109,110,111,112,113,114,162].

GCR ALEL 1Grade of Recommendation A (Level of Evidence 1)

Comments: Cognitive model of phobias. In phobias, there is a prediction of physical or psychological harm in specific situations. If the patient is able to avoid such a situation, they will not perceive a threat and will remain calm. However, if they encounter such a situation, they will experience subjective and physiological symptoms of anxiety. Fear of specific situations is based on the patient's exaggerated perception of specific negative characteristics of those situations (e.g., fear of heights, fear of dogs). In evaluative phobias, there is a fear of failure in social situations. Behavioral and physiological reactions to potential "danger" (rejection, undervaluation, failure) can significantly interfere with the patient's social functioning and, in some cases, contribute to the realization of negative expectations.

Cognitive restructuring is used as a technique in cognitive behavioral psychotherapy—interventions are carried out to correct erroneous beliefs and interpretations of bodily sensations. This can be supplemented with in vivo exposure to increase tolerance to unpleasant stimuli and obtain additional information that will disprove erroneous judgments; interoceptive exposure—increasing tolerance to internal unpleasant sensations that arise in the patient during a phobic attack; in vivo exposure—performing repeated behavioral training sessions close to real-life conditions to obtain additional information that will disprove erroneous judgments; attention focusing/distraction—during exposure, the patient's attention can be completely fixed on phobic experiences, when the patient is fully concentrated on their sensations and thoughts, reminds themselves not to get distracted, etc. The technique of behavioral experiments based on paradoxical intervention has proven effective, where the condition of the behavioral task instructs the patient to try to attract the attention of others with their absurd, funny behavior, for example, singing loudly on the street, or asking a salesperson an inappropriate question.

CBT can be delivered in both individual and group formats. Patients with social phobia tend to avoid group formats of work, as subjectively psychotraumatic, which do not allow the activation of habitual "safe" behavior mechanisms (e.g., avoidance of communication).

According to the recommendations of the UK National Collaborating Centre for Mental Health, individual cognitive behavioral psychotherapy within the framework of the D.M. Clark and A. Wells model and the R.M. Rapee and R.G. Heimberg model is recognized as the "gold standard" in the treatment of social anxiety disorder [162,218,219,220].

For individual CBT according to the D.M. Clark and A. Wells model, treatment should consist of 14 sessions lasting 90 minutes over 4 months and include:

– psychoeducation about social anxiety;

– practical exercises to demonstrate the negative consequences of self-focused attention and safety behaviors;

– video feedback to correct distorted negative self-evaluation;

– systematic training in external attention;

– in-session behavioral experiments to test negative beliefs using related homework assignments;

– training in "attitude re-writing" to cope with problematic memories of social trauma;

– exploration and modification of core beliefs;

– modification of problematic pre- and post-event processing;

– relapse prevention.

Individual CBT according to the R.M. Rapee and R.G. Heimberg model should consist of 15 sessions lasting 60 minutes and 1 session lasting 90 minutes over approximately 4 months and include:

– psychoeducation about social anxiety;

– cognitive restructuring;

– gradual exposure to anxiety-provoking social situations, both in treatment sessions and as homework;

– exploration and modification of core beliefs;

– relapse prevention.

When working with patients with social anxiety disorder within CBT, group therapy in formats such as assertiveness training, self-confidence building training, and social skills training is recognized as the most effective.

Thus, CBT in working with patients with social anxiety disorder sets the following tasks:

1. Working with irrational attitudes and false beliefs that cause anxiety in social situations. First, patients learn to track their negative thoughts, then check whether they correspond to reality, and subsequently replace them with realistic ones.

2. Acquiring social skills that a patient with social anxiety disorder usually lacks. This is achieved through group role-playing games.

3. Overcoming social skills deficits.

Patients perform special self-disclosure exercises: attend a party, return a defective purchased item to a store, initiate a conversation with someone, etc.

The development of technical capabilities has facilitated the creation of methodologies utilizing mobile applications [221,222]. Research data indicate the efficacy of cognitive behavioral psychotherapy using internet and telecommunication technologies (e.g., internet-delivered CBT) [223,224].

In cases of social phobias, the efficacy of individual and group third-wave CBT methods has also been demonstrated: metacognitive therapy (MCT), acceptance and commitment therapy (ACT), mindfulness-based cognitive therapy (MBCT), and mindfulness-based stress reduction (MBSR) techniques are used [226,227,228,229,230].

• For all patients with social anxiety disorder presenting with frequent and/or intense clinical manifestations, anticipatory anxiety, and avoidant behavior, clinical and psychological training and/or virtual reality exposure therapy (VRET)—from 8 to 12 sessions—is recommended for the purpose of reducing anxiety levels, decreasing the intensity of phobic experiences, overcoming social anxiety, and overcoming avoidant behavior [115,116,117,118,119,120,121,122,123,124,125,126,127,128,129,130,131,132,133,134,281].

GCR CLEL 3Grade of Recommendations C (Level of Evidence 3)

Comments: In vivo exposure does not always increase treatment efficacy, but it can be useful for reality testing of behavior and improving treatment adherence. Modern variants of exposure involve the active use of virtual reality capabilities. Virtual reality technology provides a digital artificially simulated space for conducting psychological interventions in real time. It involves the use of computer hardware and software technologies (e.g., stereoscopic displays) to simulate real-life events. Virtual reality technologies make it possible to create controlled digital environments that allow exposure scenarios to be tailored to specific needs and specific phobic plots. Studies confirm the efficacy of virtual reality exposure therapy (VRET) in social anxiety disorder [230,231,232,233].

• For patients with social anxiety disorder experiencing difficulties in interpersonal interaction, group short-term interpersonal psychotherapy—20 sessions of 1.5 hours, 5 sessions per week—is recommended for the purpose of reducing anxiety levels, decreasing the intensity of phobic experiences, overcoming social anxiety, improving communication skills, and overcoming avoidant behavior [2,74,135,161].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

Comments: the aim of this psychotherapy method is constructive change, primarily in the interpersonal sphere. These are achieved through the disclosure, analysis, realization, and working through of the patient's interpersonal problems, and the correction of their inadequate attitudes, mindsets, and emotional and behavioral patterns based on the analysis and use of interpersonal interaction.

In the process of psychotherapy focused on the correction of inadequate interactions, the patient's conflicting relationships lose their central character. This entails a decrease in symptom severity. Secondary reduction of intrapersonal issues is observed. The objectives of psychotherapy also focus mainly on three components of self-awareness: self-understanding (cognitive aspect), self-attitude (emotional aspect), and self-regulation (behavioral aspect). The use of group interpersonal psychotherapy in the treatment of patients with anxiety disorders makes it possible to target more specific psychotherapeutic "targets" characteristic of this group of patients—increasing avoidant behavior leading to a narrowing of social ties, severity of social phobic symptoms, deficits in the communication system, etc. The advantage of the interpersonal approach is that the patient emerges from a state of isolation, conditions are created for establishing contacts with other people, and an opportunity arises to form a more adequate self-esteem.

Carrying out this type of psychotherapy helps activate and strengthen the factor of universalization, which in this patient cohort manifests as a modification and reduction of the feeling of uniqueness regarding their own disorder, associated with the fear of death, insanity, and loss of control. Ultimately, this leads to a modification of persistent maladaptive behavioral patterns.

• For patients with social phobias who have conflicting relationships and experiences of shame or anger, it is recommended to conduct short-term dynamic psychotherapy — 25–30 sessions lasting 50 minutes over 6–8 months — in order to reduce anxiety levels and the intensity of phobic experiences, overcome social anxiety and avoidant behavior, and raise awareness of internal experiences [161,234,235].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

Comments: short-term psychodynamic psychotherapy is used in the treatment of patients with social anxiety disorder. This is a specific structured form of psychoanalytic psychotherapy focusing on the symptoms of social phobia and aspects of psychodynamics associated with the manifestations of anxiety. Treatment aims to identify the meaning of anxiety symptoms and draw attention to the manifestations of psychological defense mechanisms that suppress the awareness of denied feelings, conflicts, and fantasies associated with social anxiety.

Short-term psychodynamic psychotherapy for social phobias consists of 25–30 sessions lasting 50 minutes over 6–8 months and includes the following tasks:

– psychoeducation regarding social anxiety;

– establishment of a safe, positive therapeutic alliance to overcome the consequences of a lack of secure attachment;

– emphasis on the core focus of conflicting relationships associated with social anxiety symptoms;

– shame as a target;

– encouragement of participation in potentially anxiety-provoking social situations outside of therapy sessions;

– support in developing a self-respecting observational ego;

– assistance in improving social skills.

Clarification, confrontation, and interpretation are used as the main techniques within dynamic psychotherapy. Therapy is divided into three phases, which do not necessarily follow each other sequentially and may vary in duration depending on the patient's individual characteristics.

• For all patients with social anxiety disorders, it is recommended to use relaxation methods — 10–15 sessions — in order to reduce anxiety levels, decrease the intensity of phobic experiences, and control breathing and muscle tension [2,74,161].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

Comments: there are studies both confirming the efficacy of relaxation techniques in the treatment of functional somatic disorders and describing their limitations. The use of biofeedback enables the patient to learn how to regulate their state and monitor it.

• For patients with social anxiety disorders in whom an intrapersonal conflict is identified during history taking, it is recommended to apply individual and/or group personality-oriented (reconstructive) psychotherapy — 20–30 sessions — to reduce anxiety levels and the intensity of phobic experiences, overcome social anxiety and avoidant behavior, and improve communication skills [2,74,161,236].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

Comments: Personality-oriented (reconstructive) psychotherapy can be classified as a Russian adaptation of the psychodynamic approach. Psychotherapy aims to restore the patient's impaired system of relations through the study of their personality traits, analysis and realization of the specifics of the formation of the patient's system of relations, the pathogenic situation, and the neurotic conflict. The balanced use of therapeutic impact mechanisms (confrontation, emotionally corrective experience, and learning) makes it possible to modify the patient's impaired relations, taking into account three planes of expected changes (in the cognitive, emotional, and motivational-behavioral spheres). The main task is for the patient themselves to grasp, in the course of psychotherapy, the interrelationships between their life history, the relations formed by it, the resulting inadequate reactions to the current situation, and the manifestations of the illness — all those interrelationships of which they were previously unaware. In addition to positive dynamics at the level of symptomatic manifestations, the patient's interpersonal and social functioning, as well as their quality of life, significantly improve. The central target of psychotherapeutic interventions in personality-oriented (reconstructive) psychotherapy is self-esteem and self-attitude; in social phobias, this personality structure is always affected. The patient doubts themselves and their abilities, is dissatisfied with their own behavior and appearance, and attributes to other people the belief that those around them perceive them as negatively as they perceive themselves. A decisive moment is the restructuring of the patient's impaired relations, which completes the psychotherapy process: changes in self-perception and new ways of interacting with others help overcome social anxiety and establish interpersonal functioning.

• For patients with social anxiety disorders and insomnia, it is recommended to use a comprehensive medical and psychological treatment methodology for patients with insomnia in order to normalize sleep [237].

GPR BLEL 2Grade of Recommendation B (Level of Evidence 2)

Comments: according to research data, insomnia disorders occur in 20–70% of patients with social anxiety disorders, representing a risk factor for worsening the course of the disorder, the formation of secondary insophobia (fear of being unable to sleep), and the development of comorbid conditions [238,239,240]. The problem of insomnia is particularly relevant in cases of nomophobia ("no-mobile-phobia"), which is actively studied nowadays and occurs among 75%–100% of young people aged 18 to 35 in both developed and developing countries [241,242]. People with nomophobia experience a strong need to constantly check their mobile devices for notifications and status updates. Available data indicate a strong link between nomophobia and sleep problems [243,244].

An open, randomized, prospective, controlled parallel-group study with blinded rater assessment was conducted in accordance with the clinical approbation protocol "Comprehensive Medical and Psychological Methodology for Insomnia Treatment" (protocol index: 2020-37-3). The results of the quantitative evaluation of the clinical approbation method's efficacy were assessed using seven indicators: improvement of subjective sleep characteristics; improvement of sleep quality; reduction of the insomnia severity index; reduction of daytime sleepiness; reduction of the consequences of sleep disturbances; reduction of anxiety severity; and improvement in the clinical global impression. The target outcome was achieved across all indicators, ranging from 87% to 100%. Although an isolated sample of patients with social anxiety disorders was not singled out, a significant reduction in anxiety and the normalization of sleep make it possible to apply this methodology in patients with anxiety disorders who experience sleep disturbances, including social anxiety disorders.

The complex medical and psychological insomnia treatment program includes 10 individual cognitive behavioral psychotherapy sessions (frequency: twice a week, duration: 60 minutes) and 10 sessions of complex psychophysiological methods (frequency: 3 times a week, duration: 60 minutes), which include diaphragmatic breathing training (45 minutes) and light therapy (15 minutes). The total number of sessions is 20. The program duration is 5 weeks. During individual cognitive behavioral psychotherapy, the patient learns the basic principles of sleep hygiene, techniques aimed at independently identifying and relieving neuropsychic tension, and skills for identifying and challenging dysfunctional beliefs regarding sleep, the causes of insomnia, and methods for its correction, which overall contributes to the formation of a rational thinking system. The course of psychotherapy combined with light therapy and diaphragmatic breathing is aimed at teaching the patient self-analysis and self-regulation, which makes it possible to independently monitor and regulate one's condition, recognize the initial manifestations of pathological states, independently prevent or stop them, and seek qualified medical help in a timely manner if necessary.

4. Medical Rehabilitation and Sanatorium-Resort Treatment

• For all patients with social anxiety disorders, it is recommended to use rehabilitation measures, measures aimed at shortening the period of temporary disability, early societal socialization, and improving the quality of life [2,74].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

• For all patients with social anxiety disorders, in order to shorten the period of temporary disability, promote early societal socialization, and improve the quality of life, it is recommended to use social rehabilitation work: sociocentric and psychocentric psychotherapeutic methods [2,74].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

• For all patients with social anxiety disorders, in order to increase the quality and efficacy of treatment, clinical and psychological adaptation — family, social-psychological, and professional psychotherapy and/or psychocorrection — is recommended as special types of rehabilitation [2,74].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

• For patients with social anxiety disorders who have pronounced or prolonged phobic manifestations and avoidant behavior, supportive psychotherapy, which can be provided on an outpatient basis as individual or group therapy, is recommended as an important form of rehabilitation measures to increase the quality and efficacy of treatment [2,74].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

• For all patients with social anxiety disorders, it is recommended to undergo observation and management by a psychotherapist or psychiatrist for therapy adjustment, its correct discontinuation, and the provision of psychotherapy [2,74].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

• For all patients with social anxiety disorders, follow-up care by a psychiatrist (B04.035.001 dispensary appointment (examination, consultation) by a psychiatrist) is recommended in cases of suicidal risk, severe disease course, comorbid mental pathology, or treatment resistance, in order to dynamically assess the condition, determine indications for adjusting outpatient treatment, and ensure timely hospitalization [2,74].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

5. Prevention and Dispensary Observation

There is no specific prevention for anxiety and phobic disorders (APDs). Prevention of APDs consists in introducing the principles of a healthy lifestyle, measures aimed at maintaining mental health among the population, limiting alcohol and psychoactive substance use, as well as informing the public about the signs of APDs for early detection and timely seeking of medical care.

• All patients with APDs are recommended to adhere to the principles of a healthy lifestyle and implement measures aimed at maintaining mental health among the population in order to prevent anxiety disorders [1,2,74].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

• In order to reduce the risk of symptom aggravation, all patients with phobic and anxiety disorders (PADs) are recommended to initiate treatment as early as possible, comply with the appropriate regimen of pharmacotherapy and psychotherapy sessions, and correct comorbid health- and lifestyle-related risk factors [268,269,270,271].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

• Depending on the severity of PADs, regular outpatient follow-up by a multidisciplinary team—including a psychiatrist, psychotherapist, and social worker—is recommended for dynamic condition assessment, determining indications for therapy adjustment, and timely inpatient hospitalization [268,269,270,271].

LeR CLoE 5Level of Recommendation C (Level of Evidence — 5)

Comment: The minimum frequency of follow-up visits, if the disease course did not require patient hospitalization within 3 years, is once every 3 months; in case of hospitalization within 2 years, at least once every 2 months (during the first year, once a month).

Dispensary observation (follow-up) may be established regardless of the consent of the person suffering from a mental disorder or their legal representative in cases provided for by Part 1 of Art. 27 of the Law of the Russian Federation dated July 2, 1992, No. 3185-1 "On Psychiatric Care and Guarantees of Citizens' Rights in Its Provision" (hereinafter referred to as Law No. 3185-1).

"Decisions on the necessity of establishing dispensary observation and its termination are made by a commission of psychiatrists appointed by the head of the medical organization providing outpatient psychiatric care, or by a commission of psychiatrists appointed by the executive authority of a constituent entity of the Russian Federation in the field of healthcare" (Part 2 of Art. 27 of Law No. 3185-1). Such an examination is possible both upon voluntary request for psychiatric care and involuntarily, if there are indications for an involuntary examination.

The grounds for establishing dispensary observation are the presence of a chronic and protracted mental disorder with severe, persistent, or frequently exacerbating pathological manifestations (Part 1, Article 27 of Law No. 3185-1).

The procedure for dispensary observation of a person suffering from a chronic and protracted mental disorder with severe, persistent, or frequently exacerbating pathological manifestations is determined by the Order of the Ministry of Health of the Russian Federation dated June 30, 2022, No. 453n "On Approval of the Procedure for Dispensary Observation of a Person Suffering from a Chronic and Protracted Mental Disorder with Severe, Persistent, or Frequently Exacerbating Pathological Manifestations", which entered into force on March 1, 2023.

In accordance with the appendix to the Procedure, 5 dispensary observation groups have been defined: D-1, D-2, D-3, D-4, and D-5 (active dispensary observation), within which subgroups may be distinguished if necessary.

Upon recovery or significant and persistent improvement in an individual's mental state, dispensary observation is terminated (Part 4, Article 27 of Law No. 3185-1).

6. Organization of Medical Care

Indications for hospital admission to a medical organization:

1. high frequency of phobic attacks requiring selection of pharmacotherapy in a hospital setting;

2. severe anxiety requiring selection of pharmacotherapy in a hospital setting;

3. presence of comorbid mental disorders requiring selection of drug therapy in a hospital setting;

4. presence of comorbid somatic disorders requiring selection of drug therapy in a hospital setting;

5. severe phobic conditions with restrictive behavior, persistent agoraphobia significantly impairing the patient's mobility, severe social phobia affecting many areas of the patient's life;

6. poor tolerability of pharmacotherapy.

Indications for discharging a patient from a medical organization:

1. selection of adequate and effective pharmacotherapy;

2. absence of pronounced adverse events;

3. reduction in the frequency of phobic attacks;

4. reduction in anxiety levels;

5. stabilization of the mental state;

6. stabilization of the somatic condition;

7. relief of phobic conditions with overcoming restrictive behavior.

7. Additional Information

7.1 Factors (predictors) contributing to a protracted course

Main predictors of protracted APD course [2,29,74]

Criteria for Evaluating the Quality of Medical Care

Quality of care criteria for primary health care in adults with anxiety and phobic disorders (ICD-10 codes: F40.00, F40.01, F40.1, F40.2, F40.8, F40.9)

Quality of care criteria for specialized medical care in adults with anxiety and phobic disorders (ICD-10 codes: F40.00, F40.01, F40.1, F40.2, F40.8, F40.9)

References

Appendix A1. Working Group Composition

1. Vasileva, Anna Vladimirovna – Doctor of Medical Sciences, Associate Professor, Chief Researcher at the Department of Borderline Mental Disorders and Psychotherapy at the V.M. Bekhterev National Medical Research Center for Psychiatry and Neurology of the Russian Ministry of Health, Professor at the Department of Psychotherapy, Medical Psychology, and Sexology at the North-Western State Medical University named after I.I. Mechnikov of the Russian Ministry of Health, certified psychoanalyst of the German Academy of Psychoanalysis (DAP), Chair of the Russian Branch of the World Association for Dynamic Psychiatry (WADP). Member of the Russian Psychotherapeutic Association, member of the Russian Society of Psychiatrists.

2. Yury P. Zinchenko – Doctor of Psychological Sciences, Chief freelance specialist in medical psychology of the Russian Ministry of Health, Dean of the Faculty of Psychology at Lomonosov Moscow State University, Director of the Psychological Institute of the Russian Academy of Education, Professor, Full Member of the Russian Academy of Education, President of the Russian Psychological Society.

3. Isaeva, Elena Rudolfovna – Doctor of Psychological Sciences, Professor, Head of the Department of General and Clinical Psychology at the Pavlov First Saint Petersburg State Medical University of the Ministry of Health of the Russian Federation, Chief freelance specialist in medical psychology for the Healthcare Committee of Saint Petersburg, member of the Russian Society of Psychiatrists.

4. Karavaeva Tatiana Arturovna – MD, Associate Professor, Head of the Psychotherapy Institute, Head and Chief Researcher at the Department of Treatment of Borderline Psychiatric Disorders and Psychotherapy at the V.M. Bekhterev National Medical Research Center for Psychiatry and Neurology of the Russian Ministry of Health, Professor at the Department of Medical Psychology and Psychophysiology at Saint Petersburg State University, Professor at the Department of General and Applied Psychology with courses in Biomedical Disciplines and Pedagogy at Saint Petersburg State Pediatric Medical University of the Russian Ministry of Health, Leading Researcher at the Research Department of Innovative Methods of Therapeutic Oncology and Rehabilitation at the N.N. Petrov National Medical Research Center of Oncology of the Russian Ministry of Health, Head of the Working Group on the Development and Revision of Clinical Guidelines for "Anxiety and Phobic Disorders", Vice-President of the Russian Psychotherapeutic Association (RPA), Member of the Russian Society of Psychiatrists.

5. Mizinova Elena Borisovna – PhD in Psychology, Senior Researcher at the Department of Borderline Psychiatric Disorders and Psychotherapy at the V.M. Bekhterev National Medical Research Center for Psychiatry and Neurology of the Russian Ministry of Health, Associate Professor at the Department of Medical Psychology and Psychophysiology at Saint Petersburg State University. Member of the Russian Psychotherapeutic Association, Member of the Russian Society of Psychiatrists.

6. Ponomarenko Gennady Nikolaevich – Corresponding Member of the Russian Academy of Sciences, Honored Scientist of the Russian Federation, Professor, MD, General Director of the G.A. Albrecht Federal Scientific and Educational Center of Medical-Social Expertise and Rehabilitation of the Russian Ministry of Labor, Head of the Department of Physical and Rehabilitation Medicine at the I.I. Mechnikov North-Western State Medical University of the Russian Ministry of Health, Member of the Interregional Society of Physical and Rehabilitation Medicine.

7. Radionov Dmitry Sergeevich – Junior Researcher at the Department of Borderline Psychiatric Disorders and Psychotherapy at the V.M. Bekhterev National Medical Research Center for Psychiatry and Neurology of the Russian Ministry of Health, Member of the Russian Society of Psychiatrists.

Conflict of interest: none

Appendix A2. Methodology for Developing Clinical Guidelines

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. Psychiatrists

2. Psychotherapists

3. Medical psychologists

4. General practitioners (family physicians)

Table 1. Scale for assessing levels of reliable evidence (LRE) for diagnostic methods (diagnostic interventions)

Table 2. Levels of Evidence (LoE) grading scale for prevention, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitative interventions)

Table 3. Scale for assessing levels of evidence (LoE) for methods of prevention, treatment, and medical rehabilitation, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitation interventions)

Procedure for updating clinical guidelines.

The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

1. Order of the Ministry of Health of the Russian Federation No. 460n dated July 4, 2022 "On Approval of the Standard of Medical Care for Adults with Anxiety and Phobic Disorders (Diagnosis and Treatment)" (Registered with the Ministry of Justice of the Russian Federation on August 11, 2022, No. 69592)

Recommended doses of medications for the treatment of anxiety and phobic disorders

Appendix B. Physician Action Algorithms

Therapy algorithms for patients with AFR

SSRIs – Selective Serotonin Reuptake Inhibitors

1. For a rapid effect on anxiety and phobic symptoms, #hydroxyzine** – 25-100 mg/day can be used

2. In individual cases with a severe level of impairment, combination therapy of psychotherapy + pharmacotherapy may be prescribed.

3. Contraindications and limitations for psychotherapeutic treatment:

   – patients with a fear of self-disclosure and a predominance of denial among their psychological defense mechanisms;

   – patients with insufficient motivation for change and obvious secondary gain from illness;

   – patients with low interpersonal sensitivity;

   – patients unable to attend psychotherapy sessions regularly;

   – patients who will not participate in the process of active verbalization and listening in individual and group psychotherapy;

   – patients whose characterological features prevent them from constructively working in individual and group psychotherapy and benefiting from this work (who constantly act out their emotions as a defense reaction rather than observing their psychological state; or patients with severe negativism or rigidity).

4. Paroxetine** 20-40 mg/day; escitalopram 10-20 mg/day; sertraline** 50-200 mg/day; #citalopram 20-40 mg/day; #venlafaxine 75-225 mg/day.

5. Combination with benzodiazepine derivatives is possible in the first 3-4 weeks of treatment.

6. For a rapid effect on anxiety and phobic symptoms, #hydroxyzine** – 25-100 mg/day can be used

7. In each case of psychopharmacotherapy failure, it is first necessary to ensure the patient is compliant with the medication regimen.

8. In case of a partial response to initial treatment, the following options are available: switching the current drug to another first-line drug, prescribing combination therapy: psychotherapy + SSRIs/SNRIs (N06AX Other antidepressants). If remaining within psychopharmacotherapy, increasing the antidepressant dose to the maximum for 4-6 weeks, or adding benzodiazepine derivatives for 2-4 weeks is possible.

9. #Alprazolam 0.5-0.75 mg/day; #clonazepam 0.5-3 mg/day.

10. For a rapid effect on anxiety and phobic symptoms, #hydroxyzine** – 25-100 mg/day can be used

11. In the absence of a response to therapy with SSRIs, #venlafaxine, #trazodone, #mirtazapine, #agomelatine, or benzodiazepine derivatives, additional differential diagnosis should be performed to rule out other psychiatric conditions (obsessive-compulsive disorder, affective disorders, schizotypal disorder, schizophrenia, etc.) and neurological diseases (epilepsy, etc.). If the diagnosis of anxiety and phobic disorders is confirmed, the following treatment-resistant strategies can be used:

    – Addition of antipsychotics to the antidepressant: #sulpiride** 50-400 mg/day; #quetiapine** 50-400 mg/day

    – Prescription of antiepileptic drugs: #gabapentin 900-3600 mg/day; #pregabalin** 150-600 mg/day

12. For antidepressants, 6-12 months at the same dosage; for benzodiazepine derivatives, no more than 6 months. In the case of continued pharmacotherapy, gradual tapering of the drug with symptom monitoring is required. For psychotherapy – maintenance sessions once a month.

Algorithm for the prevention and management of patients with antidepressant discontinuation syndrome (ADS)

Note. AD – antidepressant, SSRIs – selective serotonin reuptake inhibitors, SNRIs – selective serotonin and norepinephrine reuptake inhibitors (N06AX Other antidepressants), ADDS – antidepressant discontinuation syndrome

When a decision is made to discontinue long-term antidepressant therapy, a gradual reduction in the antidepressant dose is highly preferred. When there is a high risk of antidepressant discontinuation syndrome (ADDS), an extremely slow dose reduction is advisable, although there are no universal guidelines regarding the duration of the tapering period or the minimum dose to which the antidepressant should be reduced before cessation. If ADDS cannot be avoided and is mild, drug therapy is not indicated, and it is sufficient to inform the patient about the temporary nature of the symptoms. For moderate ADDS, symptomatic treatment is necessary. For severe symptoms upon antidepressant discontinuation or significant dose reduction, the following options can be used, which are equivalent to each other and have no specific sequence of application: 1) resume the antidepressant at the minimum effective dose or at the dose where no withdrawal symptoms occurred, followed by discontinuation via more fractionated and slow titration; 2) when discontinuing an SSRI or SNRI antidepressant (N06AX Other antidepressants), one can switch to #fluoxetine**, discontinuing the original antidepressant after a few weeks of #fluoxetine** treatment and gradually tapering the latter thereafter; when discontinuing an antidepressant from other groups, one can switch to a pharmacologically similar antidepressant with a longer half-life and subsequently taper both antidepressants gradually, as in the switch to #fluoxetine** [215,216,260].

Appendix C. Patient Information

What are anxiety disorders?

Anxiety and phobic disorders are a group of nervous system disorders whose main manifestation is a persistent feeling of fear arising in the absence of real danger in specific situations.

What are the main symptoms of anxiety and phobic disorders?

Unfounded fear arising in certain situations, shortness of breath, dizziness, fear of death or imminent catastrophe, chest or abdominal pain, feeling of a "lump in the throat", avoidance of anxiety-provoking situations, anxiety at the thought of encountering such a situation, etc.

Diagnosis of anxiety and phobic disorders.

The diagnosis is usually established after ruling out all diseases that may present with similar symptoms. Diagnosis and treatment of anxiety and phobic disorders are performed by a psychotherapist or psychiatrist.

A preliminary diagnosis can be made by a general practitioner or neurologist.

Treatment of anxiety and phobic states.

Treatment of anxiety and phobic disorders includes psychotherapy and the administration of medications that reduce the feeling of fear (anxiolytics).

Psychotherapy includes various techniques that help patients with anxiety disorders correctly assess situations, achieve relaxation during anxiety attacks, and overcome avoidance or restrictive behavior. Psychotherapy can be conducted individually or in small groups. Learning behavioral strategies for various situations helps build confidence in one's ability to cope with stressful situations.

Pharmacotherapy for anxiety and phobic disorders involves the use of various agents that affect anxiety and fear. Medications that reduce anxiety are called anxiolytics (sedatives). Medical treatment—prescription, therapy adjustment, and drug discontinuation—is performed exclusively by a qualified physician.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1. Hamilton Anxiety Rating Scale (HARS)

Russian title: M. Hamilton Anxiety Rating Scale

Original title: The Hamilton Anxiety Rating Scale – (HARS) (Hamilton M., 1959).

Source (official developer website, validation publication): Hamilton M. The assessment of anxiety states by rating. Br J Med Psychol. 1959; 32: 50-55.

Type (underline):

- rating scale

- index

- questionnaire

- other (specify):

Purpose: The Hamilton Anxiety Rating Scale (HARS) is a clinical rating scale.

The Hamilton Anxiety Rating Scale (HARS) is designed to assess the state of patients with a pre-existing diagnosis of anxiety disorder and to evaluate anxiety in patients suffering from other disorders, most commonly depressive disorders.

The Hamilton Anxiety Rating Scale (HARS) is intended for healthcare professionals—general practitioners, family physicians, psychiatrists, etc. The scale is completed during a semi-structured interview, during which the clinician gathers anamnestic data and observes the patient's behavior and other non-verbal manifestations of the investigated psychopathological phenomena. The scale should not be presented to the patient, nor should direct questions from the scale be read to them.

HARS consists of 14 items, each scored on a Likert scale. 13 items relate to manifestations of anxiety in daily life, and the 14th relates to observed anxiety during the examination. Response options are standardized: each item can contribute an equal number of points to the total scale value, eliminating the need to spell out separate response options for each item, which greatly simplifies scale comprehension and scoring.

The assessment takes 20–30 minutes, during which the examiner listens to the subject's response to the question topic and rates it on a five-point scale.

Content (template):

1. Anxious mood (worries, anticipation of the worst, fearful anticipation, irritability).

0. Absent.

1. Mild.

2. Moderate.

3. Severe.

4. Very severe.

2. Tension (feelings of tension, fatigability, startle response, moving to tears easily, trembling, feelings of restlessness, inability to relax).

0. Absent.

1. Mild.

2. Moderate.

3. Severe.

4. Very severe.

3. Fears (of dark, of strangers, of animals, of traffic, of crowds, of being left alone).

0. Absent.

1. Mild.

2. Moderate.

3. Severe.

4. Very severe.

4. Insomnia (difficulty falling asleep, broken sleep, unsatisfying sleep and fatigue on waking, dreams, nightmares).

0. Absent.

1. Mild.

2. Moderate.

3. Severe.

4. Very severe.

5. Intellectual (difficulty in concentration, poor memory).

0. Absent.

1. Mild.

2. Moderate.

3. Severe.

4. Very severe.

6. Depressed mood (loss of interest, lack of pleasure in hobbies, depression, early waking, diurnal mood swings).

0. Absent.

1. Mild.

2. Moderate.

3. Severe.

4. Very severe.

7. Somatic (muscular) symptoms (pains and aches, twitching, stiffness, myoclonic jerks, teeth grinding, unsteadiness of voice, increased muscular tone).

0. Absent.

1. Mild.

2. Moderate.

3. Severe.

4. Very severe.

8. Somatic symptoms (sensory: tinnitus, blurred vision, hot or cold flashes, feeling weak, prickling sensations).

0. Absent.

1. Mild.

2. Moderate.

3. Severe.

4. Very severe.

9. Cardiovascular symptoms (tachycardia, palpitations, pain in chest, throbbing vessels, fainting feelings, sighing, dyspnea).

0. Absent.

1. Mild.

2. Moderate.

3. Severe.

4. Very severe.

10. Respiratory symptoms (pressure or constriction in chest, choking feelings, sighing, dyspnea).

0. Absent.

1. Mild.

2. Moderate.

3. Severe.

4. Very severe.

11. Gastrointestinal symptoms (difficulty in swallowing, wind, abdominal pain, burning sensations, fullness, nausea, vomiting, borborygmi, looseness of bowels, weight loss, constipation).

0. Absent.

1. Mild.

2. Moderate.

3. Severe.

4. Very severe.

12. Genitourinary symptoms (micturition frequency, urgency, amenorrhea, menorrhagia, development of frigidity, premature ejaculation, loss of libido, impotence).

0. Absent.

1. Mild.

2. Moderate.

3. Severe.

4. Very severe.

13. Autonomic symptoms (dry mouth, flushing, skin pallor, hyperhidrosis, tension headaches).

0. Absent.

1. Mild.

2. Moderate.

3. Severe.

4. Very severe.

14. Behavior during examination (fidgeting, restless gestures or gait, hand tremor, frowning, tense facial expression, sighing or tachypnea, facial pallor, frequent swallowing, etc.).

0. Absent.

1. Mild.

2. Moderate.

3. Severe.

4. Very severe.

Key (interpretation)

To obtain a total score reflecting the severity of the anxiety disorder, the scores for all items must be summed.

In addition, the first six items can be evaluated separately as psychological anxiety manifestations, and the remaining eight as somatic anxiety manifestations.

0–7 points – absence of anxiety.

8–17 points – presence of anxiety disorder symptoms.

18–24 points – moderate severity of anxiety disorder.

25–56 points – severe anxiety disorder.

Thus, the total score in individuals without anxiety is close to zero. The maximum possible total score of 56 reflects the extreme severity of the anxiety state.

Additionally, based on the severity of individual anxiety symptoms, the leading symptomatology is evaluated:

1. Anxious mood – apprehension, anticipation of the worst, anxious fears, irritability.

2. Tension – feeling of tension, startling, easily provoked crying, tremor, feeling of restlessness, inability to relax.

3. Fears – fear of the dark, strangers, animals, transport, crowds, fear of being alone.

4. Insomnia – difficulty falling asleep, broken sleep, unrefreshing sleep with a feeling of fatigue and weakness upon awakening, nightmares.

5. Intellectual impairments – difficulty concentrating, memory impairment.

6. Depressive mood – loss of usual interests, loss of pleasure from hobbies, low mood, early awakening, diurnal fluctuations in condition.

7. Somatic symptoms (muscular) – pain, muscle twitching, tension, myoclonic jerks, teeth grinding, breaking voice, increased muscle tone.

8. Somatic symptoms (sensory) – tinnitus, blurred vision, hot or cold flashes, feeling of weakness, tingling sensation.

9. Cardiovascular symptoms – tachycardia, palpitations, chest pain, vascular pulsation, feeling of weakness, frequent sighing, dyspnea.

10. Respiratory symptoms – feeling of chest pressure or tightness, smothering sensation, frequent sighing, dyspnea.

11. Gastrointestinal symptoms – difficulty swallowing, flatulence, abdominal pain, feeling of gastric fullness, nausea, vomiting, abdominal rumbling, diarrhea, weight loss, constipation.

12. Genitourinary symptoms – urinary frequency, strong urinary urgency, amenorrhea, menorrhagia, frigidity, premature ejaculation, loss of libido, impotence.

13. Autonomic symptoms – dry mouth, flushing, skin pallor, hyperhidrosis, tension headaches.

14. Behavior during examination – fidgeting, restless gestures or gait, hand tremor, frowning, tense facial expression, sighing or tachypnea, facial pallor, frequent swallowing, etc.

Appendix G2. Symptom Checklist-90-Revised

Russian title: Symptom Checklist

Original title: Symptom Check List-90-Revised, SCL-90-R (Derogatis L.R. et al., 1974). Derogatis L.R. The SCL-90-R // Clinical Psychometric Research. – Baltimore. – 1975.

Source (official developer website, validation publication): Adaptation of the method by N.V. Tarabrina, Institute of Psychology of the Russian Academy of Sciences, Laboratory of Psychology of Post-Traumatic Stress and Psychotherapy, 2001. Tarabrina N.V. Praktikum po psikhologii posttravmaticheskogo stressa. – St. Petersburg: Piter, 2001. – 272 p.

Type (underline):

- rating scale

- index

- questionnaire

- other (specify):

Purpose: SCL-90-R is a self-report scale designed to determine current psychological symptomatic status. The SCL-90-R is a clinical test and screening method intended to assess psychological symptom patterns in psychiatric patients and healthy individuals.

The SCL-90-R questionnaire consists of 90 items, each rated on a 5-point distress rating scale ranging from "not at all" to "extremely". These items measure the severity of 9 symptom dimensions that form the basis of most behavioral symptoms in psychiatric patients. Each dimension includes at least 6 items. The reliability of rating scales is proportional to the number of scale items (within certain limits). This has been confirmed by both psychometric and information theory. A small number of SCL-90-R items are not included in the 9 primary dimensions and are grouped separately as additional items.

Content (template):

Instructions. Below is a list of problems and complaints that people sometimes experience. Please read each item carefully. Circle the number of the answer that best describes the degree of your distress or anxiety caused by each problem during the past week, up to and including today. Circle only one number for each item (so that the digit inside the circle is visible), without skipping any items. If you wish to change your response, cross out your original mark.

Full Name________________________________________________ Date _____________

Key (interpretation):

Key.

Data processing

1. Scale scores – 9 indicators. Divide the sum of scores for each scale by the number of items in that scale. For example, the sum of scores for the 1st scale is divided by 12, for the 2nd by 10, etc.

2. Total score – GSI (Global Severity Index). Divide the grand total of all scores by 90 (the number of items in the questionnaire).

3. PSI (Positive Symptom Index). The number of items scored from 1 to 4 is calculated.

4. Positive Distress Symptomatical Index (PDSI). Multiply the GSI index by 90 and divide by the PSI index.

Summary table

Interpretation

1. Somatization. The items included in this scale reflect distress arising from the perception of bodily dysfunctions. The parameter includes complaints regarding the cardiovascular, gastrointestinal, respiratory, and other systems. When an organic basis for the complaints is ruled out, various somatoform disorders and anxiety equivalents are registered.

2. Obsessive-Compulsive. The core of this scale is the clinical syndrome of the same name. It includes items indicating the repetitive and unwanted nature of certain phenomena, as well as the presence of more general cognitive difficulties.

3. Interpersonal Sensitivity. The symptoms forming the basis of this scale reflect feelings of personal inadequacy and inferiority in social contacts. The scale includes items reflecting self-deprecation, feelings of awkwardness, and pronounced discomfort during interpersonal interaction. It reflects a tendency toward self-reflection and low self-esteem.

4. Depression. The items belonging to the depression scale reflect a wide range of circumstances associated with the clinical depressive syndrome. Complaints regarding a loss of interest in activities, lack of motivation, and loss of vital energy are included. The scale also includes items related to suicidal ideation, feelings of hopelessness, uselessness, and other somatic and cognitive characteristics of depression.

5. Anxiety. This scale encompasses a group of symptoms and reactions that are typically clinically associated with overt (manifest) anxiety, reflecting a feeling of oppressive, causeless internal restlessness. The basis of this scale consists of complaints of nervousness, impatience, and internal tension combined with somatic and motor manifestations.

6. Anger-Hostility. This parameter is formed from three categories of hostile behavior: thoughts, feelings, and actions.

7. Phobic Anxiety. Complaints included in this scale reflect fears associated with travel, open spaces, public places, transportation, and phobic reactions of a social nature.

8. Paranoid Ideation. In creating this scale, L.R. Derogatis et al. proceeded from the premise that paranoid phenomena are best understood when perceived as a mode of thinking. Traits of paranoid thinking of primary importance, within the limitations imposed by the questionnaire, were included in the scale. These are primarily projective thinking, hostility, suspiciousness, and ideas of reference.

9. Psychoticism. This scale is based on the following symptoms: auditory hallucinations, thought broadcasting, external control of thoughts, and intrusion of thoughts from outside. Along with these items, the questionnaire presents other indirect signs of psychotic behavior, as well as symptoms indicating a schizoid lifestyle.

Appendix G3. Integrative Anxiety Test – IAT

Russian title: Integrative Anxiety Test – IAT

Original title: Integrative Anxiety Test – IAT

Source: Developed at the Laboratory of Clinical Psychology, Bekhterev Research Institute (Bizyuk A.P., Wasserman L.I., Iovlev B.V., 1997). Bizyuk A.P. Application of the Integrative Anxiety Test (IAT) // Guidelines / A.P. Bizyuk, L.I. Wasserman, B.V. Iovlev. – St. Petersburg: Bekhterev St. Petersburg Research Psychoneurological Institute Publishing House, 2003. – 23 p.

Type (underline):

- rating scale

- index

- questionnaire

- other (specify):

Purpose: The «Integrative Anxiety Test» (IAT) methodology represents a medical (medical-psychological) technology and is an original rapid psycho-diagnostic tool for differentiated assessment and qualitative evaluation across 5 factors (subscales) of anxiety as a non-specific affective regulator of personality behavior (complex in genesis) and anxiety as a personality-typological characteristic. Analysis of the adaptogenic and pathogenic role of the «anxiety-anentrepidity tandem» helps clarify therapy mechanisms and evaluate the effectiveness of treatment for mental maladjustment of various origins.

To assess the significance level for respondents of 15 statements across the self-assessment of state anxiety (ST-S) and self-assessment of trait anxiety (ST-L) scales, the traditional 4-point rating system of subjective personal scaling is used: 0 – absence of the given trait, two others are associated with the presence of weakly and moderately expressed traits (scores 1 and 2), and the last – as an extreme degree of severity from the respondent's perspective – 3 points. Thus, the maximum number of raw scores that can be obtained on both ITT scales is 45.

Content (template):

Registration form of the trait anxiety scale (ST-L SCALE)

Full Name ______________________________________________

Age ___________________

Examination Date ____________

Examination Place _______________________________

Below are several statements concerning your emotional state. For each of them, you need to decide – HOW OFTEN over the recent period (for example, over the past year) you have experienced it. Depending on this, place a "+" sign in one of the four columns.

Registration form of the state anxiety scale (ST-S SCALE)

Full Name __________________________________________________ Age_______________

Examination Date ____________ Examination Place _______________________________

Below are several statements concerning your emotional state. For each of them, you need to decide – to what extent this state is expressed RIGHT NOW, AT THIS MOMENT, TODAY. Depending on this, place a "+" sign in one of the four columns.

Key (interpretation)

Key

Conversion table to stanines for the general personal anxiety score and the general situational anxiety score

Table for calculating auxiliary scale scores

Conversion of auxiliary scale scores to stanines for adults and adolescent males

Conversion of auxiliary scale scores to stanines for adolescent females

Interpretation

High scores on the "Emotional Discomfort" (ED) subscale indicate a lowered emotional background, dissatisfaction with life situation, emotional tension, and lack of emotional balance.

High scores on the "Asthenic Anxiety Component" (AAC) subscale point to asthenia, weakness, lethargy, increased mental exhaustion, and fatigue.

High scores on the "Phobic Component" (PHOB) subscale indicate that phobias (worry and fears caused by the current life situation) dominate the structure of anxiety.

High scores on the "Anxious Perspective Appraisal" (APA) subscale indicate that the structure of anxiety is dominated by fears oriented not so much toward the current state of affairs as toward the future and perspective, following the principle of "what if something happens".

The 5th subscale, "Social Defense Reactions" (SDR), is associated with the main manifestations of anxiety in the sphere of social contacts, with attempts by the subject to view the social environment as the main source of anxiety tension and self-doubt.

Appendix G4. C.D. Spielberger, Yu.L. Khanin Anxiety Assessment Scale

Russian title: C.D. Spielberger, Yu.L. Khanin Anxiety Assessment Scale

Original title: State-Trait Anxiety Inventory – STAI (Spielberger C.D., 1964).

Source: Spielberger C.D., Gorsuch R.L., Lushene R.E. Manual for the State-Trait Anxiety Inventory. // Palo Alto, CA: Consulting Psychologists Press. – 1970. Spielberger C.D. Test Anxiety Inventory: Preliminary professional manual. – Menlo Park. – 1980. Adaptation of the method by Yu.L. Khanin. Khanin Yu.L. Brief guide to the C.D. Spielberger reactive and personal anxiety scale. – Leningrad. – 1976. – 18 p.

Type (underline):

- rating scale

- index

- questionnaire

- other (specify):

Purpose: The C.D. Spielberger, Yu.L. Khanin Anxiety Assessment Scale is a self-assessment scale for the level of anxiety at the present moment (reactive anxiety as a state) and personal anxiety (as a stable personality characteristic). It is used in clinical practice to determine the severity of anxiety experiences, assess condition dynamics, etc. Comparing the results of both subscales makes it possible to evaluate the individual significance of a stressful situation for the subject.

Content (template)

Instructions

Situational Anxiety Scale

Read each of the statements below carefully and cross out the number in the corresponding column on the right depending on how you feel at the present moment. Do not spend too long thinking about the questions, as there are no right or wrong answers

Instructions

Personal Anxiety Scale

Read each of the following sentences carefully and cross out the number in the corresponding column on the right depending on how you usually feel. Do not dwell on the questions for long, as there are no right or wrong answers.

Key (interpretation):

When analyzing self-assessment results, keep in mind that the total score for each subscale can range from 20 to 80 points. Moreover, the higher the total score, the higher the level of anxiety (state or trait).

The level of state anxiety is calculated using the formula:

SA = ∑dp - ∑do + 50, where:

SA is the state anxiety score;

∑dp is the sum of scores for direct questions (3, 4, 6, 7, 9, 12, 14, 15, 17, 18);

∑do is the sum of scores for reverse questions (1, 2, 5, 8, 10, 11, 13, 16, 19, 20).

To calculate the level of trait anxiety, the formula is used:

TA = ∑tp - ∑to + 35, where:

TA is the trait anxiety score;

∑tp is the sum of scores for direct questions (22, 23, 24, 25, 28, 29, 31, 32, 34, 35, 37, 38, 40);

∑to is the sum of scores for reverse questions (21, 26, 27, 30, 33, 36, 39).

Interpretation

up to 30 points – low anxiety,

31–44 points – moderate;

45 and above – high.

Individuals categorized as having high anxiety tend to perceive a threat to their self-esteem and functioning across a wide range of situations and to react with a very pronounced state of anxiety. If a psychological test reveals a high trait anxiety score in a subject, this gives grounds to assume that they will experience a state of anxiety in various situations, especially when these involve the evaluation of their competence and prestige.

Individuals with a high anxiety score should cultivate a sense of confidence and success. They need to shift the focus from external demands, categoricalness, and high task significance to a meaningful understanding of the activity and concrete planning by subtasks.

For low-anxiety individuals, conversely, it is necessary to awaken activity, emphasize the motivational components of the activity, stimulate interest, and highlight the sense of responsibility in solving specific tasks.

The state of reactive (situational) anxiety occurs when encountering a stressful situation and is characterized by subjective discomfort, tension, restlessness, and autonomic arousal. Naturally, this state varies in time and intensity depending on the impact of the stressful situation. Thus, the value of the total score on this subscale allows one to assess not only the subject's current level of anxiety, but also to determine whether they are under the influence of a stressful situation and what the intensity of this impact is.

Trait anxiety is a constitutional trait that predisposes an individual to perceive threat across a wide range of situations. With high trait anxiety, each of these situations will have a stress impact on the subject and cause pronounced anxiety. Very high trait anxiety directly correlates with the presence of a neurotic conflict, emotional and neurotic breakdowns, and psychosomatic disorders.

Appendix G5. A. Beck Anxiety Inventory

Russian title: Beck Anxiety Inventory

Original title: The Beck Anxiety Inventory – (BAI), (Beck A.T., 1961).

Source: Beck A.T. et al. An Inventory for Measuring Depression // Archives of general psychiatry. – 1961. – Vol. 4. – No. 6. – P. 561-571.

Type (underline):

- rating scale

- index

- questionnaire

- other (specify):

Purpose: A clinical test designed to screen for anxiety and assess its severity.

The Beck Anxiety Inventory is designed for preliminary assessment of the severity of anxiety disorders in a wide range of individuals: adolescents from 14 years of age, adults and the elderly, clinic populations, and for screening studies.

The questionnaire consists of 21 items. Each item includes one of the typical symptoms of anxiety, whether physical or psychological. Each item is rated by the respondent from 0 (not at all) to 3 (severely).

Content (template):

Instructions.

This list contains the most common symptoms of anxiety. Please study each item carefully. Indicate how much you have been bothered by each of these symptoms DURING THE PAST WEEK, up to and including today, by putting a cross in the corresponding column on the right.

Key (interpretation)

The score is calculated by simply summing the points across all items of the BAI scale.

Scores from 0 to 9 indicate the absence of anxiety.

Scores from 10 to 21 indicate a mild level of anxiety.

Scores from 22 to 35 correspond to moderate anxiety.

Scores from 36 to 63 indicate very severe anxiety.

Appendix G6. D. Sheehan Anxiety Self-Assessment Scale

Russian title: Sheehan Patient-Rated Anxiety Scale

Original title: Sheehan Patient-Rated Anxiety Scale – (SPRAS), (David V. Sheehan, 1983).

Source: Sheehan D.V., Sheehan Kr. // Int. J. Psychiatr. Med. – 1983. – N 12. – P. 243-266.

Type (underline):

- rating scale

- index

- questionnaire

- other (specify):

Purpose: The Sheehan Patient-Rated Anxiety Scale is designed for screening and self-assessment of anxiety spectrum disorders in adults.

The scale was developed based on a sample of symptoms of anxiety disorders and panic attacks and includes the most common manifestations of these disorders, including somatic and autonomic manifestations of anxiety. Each item is rated on a Likert scale from 0 to 4 points.

Content (template):

Instructions.

Determine how much you have been bothered by the symptoms listed below over the past week. Mark your answer number on the answer sheet.

Key (interpretation):

The total score on the scale is equal to the sum of the scores of all items. Thus, the total score can range from 0 to 140.

0–29 – absence of clinically significant anxiety,

30–79 – clinically significant anxiety,

80 and above – severe anxiety disorder, panic disorder.

According to clinical studies, scores on the Sheehan Anxiety Scale for panic disorder and agoraphobia (in neurotic disorders) range from 37 to 77 points.

Appendix G7. Minnesota Multiphasic Personality Inventory (MMPI)

Russian title: Standardized Clinical Personality Questionnaire, adapted by L.N. Sobchik et al. (SMIL), 1970.

Original title: Minnesota Multiphasic Personality Inventory – (MMPI) (Hathaway & McKinley, 1943) Hathaway, S. R., & McKinley, J. C. (1943). The Minnesota Multiphasic Personality Inventory. Minneapolis: University of Minnesota Press. Copyright © 1943 (renewed 1970); Hathaway S.R., McKinley J.C. The Minnesota Multiphasic Personality Inventory manual. N.Y., Psychological Corporation, 1960.

Source: Adaptation of the method by L.N. Sobchik, V.P. Serbsky Institute of Forensic Psychiatry, 1971. Sobchik L.N., Standartizirovannyi mnogofaktornyi metod issledovaniya lichnosti SMIL (MMPI) Prakticheskoe rukovodstvo. – M.: Rech, 2007. – 224 p.

Type (underline):

- rating scale

- index

- questionnaire

- other (specify):

Purpose: The MMPI questionnaire is designed to study individual personality traits, emotional state, and coping mechanisms in adults.

The questionnaire text includes 566 items covering health status, habits, behavior, prevailing experiences and mood, attitudes toward various life events, interpersonal relationships, and orientation of interests. Processing yields scores on 10 basic scales as well as 3 validity scales designed to determine the subjects' attitude toward testing, evasiveness, or intentional distortion of results.

Appendix G8. Ich Struktur Test nach G. Ammon – G. Ammon Ego-Structural Test (1978) (ISTA)

Russian title: G. Ammon Ego-Structural Test.

Original title: Ich-Struktur-Test nach G. Ammon (ISTA).

Source: Ammon G. Das Verständnis eines Entwicklungsdefizits von Ich-Strukturen in Persönlichkeit und umgebender Gruppe als Grundlage für Wissenschaft und Praxis einer Dynamischen Psychiatrie. — Dynamische Psychiatrie, 1978, Jg. 11, s. 120-140.

Source (official developer website, publication with validation): Adapted and re-standardized at the V.M. Bekhterev Saint Petersburg Research Institute. Ego-Strukturnyi test Ammona. Oprosnik dlya otsenki tsentralnykh lichnostnykh funktsii na strukturnom urovne: posobie dlya psikhologov i vrachei / avt.-sost. Yu.Ya. Tupitsyn, V.V. Bocharov, T.V. Alkhazova et al. – SPb.: Nauch.-issl. psikhonevr. inst. im. V.M. Bekhtereva, 1998 – 70 p.

Type (underline):

- rating scale

- index

- questionnaire

- other (specify)

Purpose: A questionnaire developed by the author and his colleagues. It evaluates central personality functions: aggression, anxiety/fear, external and internal ego boundaries, narcissism, and sexuality.

The questionnaire includes 220 items distributed across 18 scales, providing insight into constructive, destructive, and deficient manifestations of personality. The scope of the test is personality diagnostics in individuals suffering from neurosis, borderline syndrome, and psychosis. ISTA is based on the structural model of personality. Regarding validity, ISTA significantly and in the expected direction indicates differences between clinical groups and healthy individuals. The test reliably reflects changes during the therapeutic process.

Appendix G9. Locus of Control Questionnaire (LCQ)

Russian title: Level of Subjective Control Questionnaire (LSC).

Original title: Rotter's Locus of Control Scale – Rotter, Julian B (1966). Generalized expectancies for internal versus external control of reinforcement. Psychological Monographs: General and Applied. 80(1): 1–28. doi:10.1037/h0092976; Rotter, J. B. Social learning and clinical psychology. — New York: Prentice-Hall, 1954.

Source (official developer website, publication with validation): Bazhin E.F., Golynkina E.A., Etkind A.M. Metod issledovaniya urovnya subektivnogo kontrolya // Psikhologicheskii zhurnal. — Vol. 5. — 1984. — No. 3. — P.152-162.

Type (underline):

- rating scale

- index

- questionnaire

- other (specify)

Purpose: The questionnaire consists of 44 statements and is designed to diagnose internality-externality. It measures both the general level of internality and the personality's locus of control in various spheres of life. The level of subjective control is a generalized personality characteristic that manifests similarly in various situations.

The level of subjective control is associated with a person's sense of responsibility for the events occurring in their life. The behavioral strategies a person chooses may vary and depend on their social maturity and independence. Depending on how a person assesses life events, what they consider the cause of these events to be, and who bears responsibility for them, they are classified as either "internals" or "externals". Unlike J. Rotter's original scale, the LSC questionnaire includes items measuring internality-externality in interpersonal and family relationships. Since the questionnaire is intended for medical and psychological research, it includes items measuring LSC in relation to health and illness.

Appendix G10. "Personal Beliefs Test" (Kassinove H., Berger A., 1988) – Personal Beliefs Questionnaire

Russian title: Personal Beliefs Questionnaire.

Original title: Personal Beliefs Test (Kassinove Howard, 1988) - Kassinove H., Berger A. Survey of personal beliefs // Hofstra University: Personal communication — 1988. — P. 100–113.

Source (official developer website, validation publication): Adaptation of the method carried out at the V.M. Bekhterev SPbNIPNI. - Nazyrov R.K., Logacheva S.V., Remeslo M.B., Kholyavko V.V., Pavlovsky I.O. Tipologiya psikhoterapevticheskikh mishenei i ee ispolzovanie dlya povysheniya kachestva individualnykh psikhoterapevticheskikh programm v lechenii bolnykh s nevroticheskimi rasstroistvami // Metodicheskie rekomendatsii. — SPb.: Izdatelstvo NIPNI im. V.M. Bekhtereva. — 2011.

Type (underline):

- rating scale

- index

- questionnaire

- other (specify)

Purpose: The questionnaire was originally developed at Hofstra University (USA)

by Howard Kassinove and Andrew Berger (1981) and is intended to diagnose rationality of thinking and identify irrational beliefs (attitudes) characteristic of patients with neurotic disorders. The methodological basis for its creation was Albert Ellis's rational-emotive psychotherapy. Later, the authors introduced certain changes to the questionnaire content, the appropriateness of which was confirmed by factor analysis. The questionnaire includes 5 scales:

1. "Self-directed shoulds". 2. "Self-evaluation". 3. "Catastrophizing". 4. "Other-directed shoulds". 5. "Low frustration tolerance". and 6. General (integral) index of thinking rationality. The main purpose of the questionnaire is to study respondents' rational and irrational ideas (attitudes).

Appendix G11. Life Style Index (LSI)

Russian title: Life Style Index.

Original title: Life style index (LSI, Kellerman-Plutchik, 1979). Plutchik R. A structural theory of ego defence and emotions / Emotions in personality and psychopathology / R. Plutchik, H. Kellerman, H. Conte; Ed. by E. Izard. - New York, 1979. - p. 229-257.

Source (official developer website, validation publication): Adaptation of the method by L.I. Wasserman et al., V.M. Bekhterev Saint Petersburg Psychoneurological Research Institute, Laboratory of Clinical Psychology. - Wasserman L.I., Eryshev O.F., Klubova E.B. et al. Psikhologicheskaya diagnostika indeksa zhiznennogo stilya: metodicheskoe posobie dlya vrachei i psikhologov. - SPb.: NIPNI im. V.M. Bekhtereva, 1998. - 48 p.

Type (underline):

- rating scale

- index

- questionnaire

- other (specify):

Purpose: A personality questionnaire designed to assess the severity of 8 main psychological defense mechanisms (8 scales obtained via factor analysis): denial, projection, regression, compensation, repression, displacement, intellectualization, and reaction formation. The questionnaire consists of 97 questions and assesses the frequency of use of a particular defense mechanism in daily life. Scoring and conversion into scaled scores (percentiles) are performed using special tables. The combination of scaled scores reflects the individual structure of the person's psychological defenses and their overall style of defensive behavior.

Appendix G12. Coping Strategies (CS).

Russian title: R. Lazarus Coping Strategies methodology.

Original title: "Ways of Coping Questionnaire" (WCQ, Folkman S., Lazarus R., 1988). - Folkman S., Lazarus R. Manual for ways of coping questionnaire. - Palo Alto, CA: Consult. Psychol. Press, 1988.

Source (official developer website, validation publication): Adaptation of the method by L.I. Wasserman et al., V.M. Bekhterev Saint Petersburg Psychoneurological Research Institute, Laboratory of Clinical Psychology. - Wasserman L.I., Iovlev B.V., Isaeva E.R. et al. Metodika dlya psikhologicheskoi diagnostiki sposobov sovladaniya so stressom i problemnymi dlya lichnosti situatsiyami / Posobie dlya vrachei i meditsinskikh psikhologov. - Izd-vo NIPNI im. V.M. Bekhtereva. - SPb, 2009. - 40 p.

Type (underline):

- rating scale

- index

- questionnaire

- other (specify):

Purpose: The questionnaire is widely used in domestic research to study stress-coping behavior (coping). The theoretical basis of the questionnaire is R. Lazarus's transactional model of stress adaptation (1966). The questionnaire includes 50 statements combined into 8 scales (obtained via factor analysis). Each scale represents a specific standard behavioral option in a difficult situation: planned problem solving, positive reappraisal, accepting responsibility, seeking social support, confrontation, self-control, distancing, and avoidance. Raw scores are calculated for each scale and converted into T-scores (percentiles) using a special formula. The aggregate of the obtained T-scores reflects the individual structure (repertoire) of stress-coping behavior, while the highest scores on one of the scales indicate the predominance of the corresponding coping strategy in a person's coping behavior.

Appendix G13. Melbourne Decision Making Questionnaire (MDMQ)

Russian title: Melbourne Decision Making Questionnaire.

Original title: Melbourne Decision Making Questionnaire – MDMQ. Mann L., Burnett P., Radford M., Ford S. The Melbourne Decision Making Questionnaire: An Instrument of Measuring Patterns for Coping with Decisional Conflict. Journal of Behavioral Decision Making, 1997, 10(1), 1–19.

Source (official developer website, validation publication): Adaptation of the methodology - Kornilova T.V. Melbourne Decision Making Questionnaire: A Russian Adaptation, Lomonosov Moscow State University, Faculty of Psychology. - Kornilova T.V. New questionnaire of tolerance-intolerance to uncertainty // Psychological Journal. 2010. Vol. 31. No. 1. pp. 74–86; Kornilova T.V. Melbourne Decision Making Questionnaire: Russian-language adaptation // Psychological Studies. – 2013. – Vol. 6. – No. 31.

Type (underline):

- rating scale

- index

- questionnaire

- other (specify):

Purpose: This is a personality questionnaire aimed at diagnosing

an individual decision-making style. The questionnaire is the result of piloting the more general Flinders' Decision Making Questionnaire (DMQ).

Validated in Russian by T.V. Kornilova, S.A. Kornilov, and M.A. Chumakova in 2010. Psychological studies of human decision-making under conditions of uncertainty include both the analysis of cognitive components and personal aspects of choice regulation.

The Melbourne Decision Making Questionnaire includes 22 statements, agreement with which is rated by the respondent on a 3-point scale. It allows for diagnosing four traits interpreted as productive (vigilance) and unproductive coping (avoidance, procrastination, and hypervigilance) in decision-making situations. Approximate testing time is 5-10 minutes.

Appendix G14. KON-2006 Neurotic Personality Questionnaire

Russian title: Neurotic Personality Questionnaire KON-2006

Original title: Kwestionariusz osobowości nerwicowej KON-2006 (Aleksandrowicz J., et al., 2006).

Source (guidelines for the use of the methodology): Aleksandrowicz J., Klasa K., Sobański J., Stolarska D. Kwestionariusz osobowości nerwicowej KON – 2006, Komitet Redakcyjno-Wydawniczy Polskiego Towarzystwa Psychiatrycznego, Biblioteka Psychoterapii Polskiej, Kraków, 2006, p. 72.

Source (official developer website, validation publication): adaptation of the methodology - Isurina G.L., Trąbczyński P.K., Saint Petersburg State University, Faculty of Psychology. Comparative study: Isurina G.L., Grandilevskaya I.V., Trąbczyński P.K. "KON-2006 Questionnaire" – a new method for studying neurotic personality traits / Medical Psychology in Russia: Electron. Sci. J. – 2017. – Vol. 9, No. 6(47), Galina L. Isurina, Irina V. Grandilevskaya, Piotr K. Trabczynski The experience of using the "Neurotic Personality Questionnaire KON-2006" in Russia Archives of Psychiatry and Psychotherapy, 2019; 1: 74–86., Isurina G.L., Grandilevskaya I.V., Trabczynski P.K., Gorbunov I.A. Neurotic Personality Questionnaire KON-20016 Methodological Recommendations St. Petersburg 2018 - 62 p.

Type (underline):

- rating scale

- index

- questionnaire

- other (specify):

Purpose: The KON-2006 Questionnaire is intended for the clinical diagnosis of neurotic-spectrum personality traits and the assessment of the general severity level of neurotic disorders. Based on the self-report method, the questionnaire makes it possible to assess the degree of personality dysfunction. Changes in this indicator occurring during treatment also make it possible to evaluate the effect of therapy on neurotic personality characteristics, and, consequently, to evaluate the results of psychotherapy (Aleksandrowicz J., 2006, Galina L. Isurina, Irina V. Grandilevskaya, Piotr K. Trabczynski, 2019).

The questionnaire includes 243 statements that form 24 scales. Raw scores are calculated for each scale, with each keyed response scored as 1 point. Then, raw scores for each scale are converted into standard scores (sten scores) adjusted for sex. Based on the standard scores for each scale, the X-KON index is calculated, characterizing the total volume of personality dysfunctions of the neurotic register. Based on the value of the X-KON index, the total severity of neurotic personality characteristics (the volume of personality dysfunctions) can be assessed.

The assessment takes 20-30 minutes, during which the examinee records their answers (YES/NO) on a response sheet. The KON-2006 questionnaire is intended for psychiatrists, psychotherapists, and clinical psychologists.

Appendix G15. Russian Universal Questionnaire for Quantitative Assessment of Treatment Adherence (KOP-25)

Russian title: Russian Universal Questionnaire for Quantitative Assessment of Treatment Adherence (KOP-25).

Original title: Russian Universal Questionnaire for Quantitative Assessment of Treatment Adherence (KOP-25).

Source (official developer website, validation publication): Nikolaev N.A., Skirdenko Yu.P. Russian Universal Questionnaire for Quantitative Assessment of Treatment Adherence (KOP-25). Clinical Pharmacology and Therapy, 2018, 27(1), 74 - 78.

Type (underline):

- rating scale

- index

- questionnaire

- other (specify):

Purpose: A clinical and psychological testing methodology designed for the quantitative assessment of treatment adherence in routine clinical practice. A standardized version of the questionnaire for quantitative assessment of treatment adherence is proposed and recommended for inclusion in the standard medical examination program for patients with chronic diseases. It can be used to identify patient cohorts requiring additional attention as poorly adherent to treatment. KOP-25 characteristics: sensitivity – 93%, specificity – 78%, reliability – 94%.

The questionnaire is filled out by the respondent personally or with the assistance of an interviewer, and includes 25 questions with response options. It is filled out sequentially – from question 1 to 25. For each question, the respondent selects the most appropriate answer from the provided closed-ended list containing 6 possible options. Only one answer can be selected for each questionnaire question. The completed questionnaire is processed by the interviewer according to an algorithm. Results processing can be performed in both automated and manual modes. There are 6 scored response options for each question. Results processing is carried out in two stages.

At the first stage, technical indicators are calculated: "importance of pharmacotherapy", "importance of medical care", "importance of lifestyle modification", as well as "readiness for pharmacotherapy", "readiness for medical care", and "readiness for lifestyle modification". Each technical indicator is a simple sum of scores obtained from responses to the corresponding questions. The minimum possible value for each technical indicator is 5 points, and the maximum is 30 points.

At the second stage, adherence indicators are calculated: "adherence to pharmacotherapy", "adherence to medical care", "adherence to lifestyle modification", and the integral indicator "treatment adherence". Each indicator represents a value calculated for a specific respondent and expressed as a percentage of the theoretically possible maximum (taken as 100%).

Appendix G16. Liebowitz Social Anxiety Scale

Russian title: Liebowitz Social Anxiety Scale

Original title: Liebowitz Social Anxiety Scale – LSAS (Liebowitz M.R. 1987)

Source (official developer website, validation publication): Liebowitz MR. Social phobia. Mod Probl Pharmacopsychiatry. 1987; 22:141-73. doi: 10.1159/000414022. PMID: 2885745.

Grigoryeva, I.V., Enikolopopov, S.N. Approbation of the "Liebowitz Social Anxiety Scale" and "Brief Fear of Negative Evaluation Scale" questionnaires // National Psychological Journal. – 2016. – No. 1(21). – P. 31-44.

Type (underline):

- rating scale

- index

- questionnaire

- other (specify):

Purpose: The methodology is intended for diagnosing the level of social anxiety and its impact on social adaptation.

The Liebowitz Social Anxiety Scale (Liebowitz, 1987) consists of descriptions of 24 social situations, in each of which the subject is asked to assess the intensity of emerging fear (or anxiety) and the frequency of avoiding a particular social situation. Scoring is performed using a 4-point Likert scale, where 0 indicates no fear/avoidance, and 3 indicates severe fear/complete avoidance. Social situations are divided into interaction situations and performance situations (situations in which the individual is potentially subject to observation).

Thus, the "Liebowitz Social Anxiety Scale" contains 4 subscales:

1) social interaction fear subscale;

2) fear subscale for situations where the individual may become the object of observation by others;

3) social interaction avoidance subscale;

4) avoidance subscale for situations where the individual may become the object of observation by others.

In addition, the total score for the fear subscales and the total score for the avoidance subscales are calculated separately, reflecting the tendency to experience fear/tendency to avoid across a wide range of social situations.

The total score across all scales is used to assess the severity of social anxiety.

Content (template):

Instructions.

Below you will find descriptions of 24 situations. Answers must be given based on events from the past week up to and including today. You determine how anxious you were in the described situation, or would have been (had it occurred). You determine this using a 4-point scale.

Also, in the second column, indicate to what degree you avoid or would avoid this type of situation using a 4-point scale.

Calculate the sum of scores in both columns

Key (interpretation):

55–65 – Mild social phobia.

65–80 – Moderate social phobia.

80–95 – Severe social phobia.

Greater than 95 – Very severe social phobia.

Appendix G17. Brief Fear of Negative Evaluation Scale

Russian title: Brief Fear of Negative Evaluation Scale

Original title: Brief Fear of Negative Evaluation Scale – BFNE (Watson, Friend, 1969; Carleton et al., 2006)

Source (official developer website, validation publication): Watson, D., & Friend, R. (1969) Measurement of Social-evaluative Anxiety. Journal of Consulting and Clinical Psychology. 33 (4), 448-457

Carleton, N.R., McCreary, D.R., Norton, P.J., & Asmundson, G.J.G. (2006) Brief Fear of Negative Evaluation Scale-Revised. Depression and Anxiety. 23, 297-303.

Grigoryeva, I.V., Enikolopopov, S.N. Approbation of the "Liebowitz Social Anxiety Scale" and "Brief Fear of Negative Evaluation Scale" questionnaires // National Psychological Journal. – 2016. – No. 1(21). – P. 31-44.

Type (underline):

- rating scale

- index

- questionnaire

- other (specify):

Purpose: The method is designed to measure the fear of negative evaluation, the core construct underlying social anxiety.

The Brief Fear of Negative Evaluation Scale (Watson, Friend, 1969; Carleton et al., 2006) contains 12 statements. The respondent is asked to rate how well each statement characterizes them on a five-point Likert scale, where 1 means "not at all characteristic of me" and 5 means "extremely characteristic of me".

It is assumed that this questionnaire measures the core construct underlying social phobia – the fear of negative evaluation.

Content (template):

Instructions.

Read the following statements carefully and determine how well each of them characterizes you:

1 – Not at all characteristic of me

2 – Slightly characteristic of me

3 – Moderately characteristic of me

4 – Very characteristic of me

5 – Extremely characteristic of me

Based on the responses to each question, 1 to 5 points are awarded. The total score is calculated.

Key (interpretation):

12–23 – Low level of fear of negative evaluation

24–46 – Moderate level of fear of negative evaluation

47–60 – High level of fear of negative evaluation

Appendix G18. Gelotophobia Questionnaire

Russian title: Gelotophobia Questionnaire

Original title: GELOPH <15> (Ruch W., Proyer R.T., 2008)

Source (official developer website, validation publication): Ruch W., Proyer R.T. Who is gelotophobic? Assessment criteria for the fear of being laughed at // Swiss Journ. of Psychology. 2008. V. 67(1). Р. 19–27.

Stefanenko, E.A., Ivanova, E.M., Enikolopov, S.N., Proyer, R., Ruch, W. Diagnostika strakha vyglyadet' smeshnym: russkoyazychnaya adaptatsiya oprosnika gelotofobii [Diagnostics of the fear of looking ridiculous: Russian-language adaptation of the gelotophobia questionnaire] / [et al.] // Psikhologicheskiy zhurnal. - 2011. - Vol. 32, - No. 2. - P. 94-108.

Type (underline):

- rating scale

- index

- questionnaire

- other (specify):

Purpose: The method is designed to identify gelotophobia – the fear of looking ridiculous and becoming an object of ridicule.

It is a questionnaire consisting of 15 affirmatively phrased items for the subjective assessment of gelotophobia.

Content (template):

Instructions.

The statements below refer to your feelings, actions, and overall perception. Please try, as much as possible, to describe your habitual behaviors and attitudes by checking one of the four response options:

1 – Strongly disagree

2 – Disagree

3 – Agree

4 – Strongly agree

Based on these answers, from 1 to 4 points are scored for each of the questions.

The sum of points scored for the subscales and the total sum of points scored are calculated. Next, the average indicator for the subscales and the overall average indicator are calculated.

Subscales:

Key (interpretation):

Overall mean:

1-1.2 – low score

1.3-2.2 – medium score

2.3-4 – high score

Appendix G19. Clinical Global Impression Scale (CGI)

Russian title: Clinical Global Impression Scale

Original title: Clinical Global Impression Scale, CGI

Source (official developer website, validation publication): Guy W., editor. ECDEU Assessment Manual for Psychopharmacology. Rockville, MD: US Department of Health, Education, and Welfare Public Health Service Alcohol, Drug Abuse, and Mental Health Administration;1976

Type (underline):

- rating scale

- index

- questionnaire

- other (specify):

Purpose: It consists of 3 subscales reflecting the assessment of symptom severity, the overall degree of improvement on a 7-point scale, and an efficacy index subscale, which is calculated based on a combination of one of four degrees of therapeutic effect (marked, moderate, minimal, unchanged) and the severity of side effects of the drug (none, minor, significant, outweighing therapeutic effect). The CGI scale is used after a clinical assessment of the patient's condition using other scales (comparing assessment results before treatment and after completing a stage or the entire course of treatment).

Content (template):

Instructions.

1. Considering your overall clinical experience with this particular patient population, how severe is the patient's mental illness at this time?

2. Rate total improvement whether or not, in your judgment, it is due entirely to drug treatment. Rate compared to condition at admission to the project.

3. Efficacy index: Rate this item on the basis of drug effect only. Select the terms that best describe the degree of therapeutic effect and side effects and record the number in the cell where the two items intersect.

Example: therapeutic effect is rated as "moderate" and side effects are rated as "do not significantly affect the patient's functional status".

Significant Significant 1 2 3 4 improvement.

Complete or near-complete remission of all symptoms

Moderate Moderate 5 6 7 8 improvement.

Partial remission of symptoms

Minimal

Minimal 9 10 11 12 improvement that does not alter patient care status

Unchanged or worse 13 14 15 16

Note: 0 – not assessed

Key (interpretation):

CGI is rated on a 7-point scale, with the severity of illness scale using a response range from 1 (Normal) to 7 (Among the most extremely ill patients).

CGI-C (Clinical Global Improvement or Change) ratings range from 1 (Very much improved) to 7 (Very much worse).

Explanations. Treatment response assessment should take into account both therapeutic efficacy and treatment-related side effects, ranging from 0 (Significant improvement and no side effects) to 4 (No change or worse and side effects outweigh the therapeutic effect). Each CGI item is scored separately; the scale does not yield a total score.