Panic disorder: clinical guidelines

List of Abbreviations

EMDR - Eye Movement Desensitization and Reprocessing

ICD - International Classification of Diseases

MRI — magnetic resonance imaging

PA - panic attack

PD - panic disorder

RCTs – randomized clinical trials

ADSS - antidepressant discontinuation/withdrawal syndrome

BAI (The Beck Anxiety Inventory) - Beck Anxiety Inventory

CGI (Clinical global impression scale) - Clinical Global Impression scale

COPE (Coping) - coping inventory

HARS (The Hamilton Anxiety Rating Scale) - Hamilton Anxiety Rating Scale

IIP (Inventory of Interpersonal Problems) - Inventory of Interpersonal Problems

ISTA (Ich-Struktur-Test nach G. Ammon) - G. Ammon and I. Burbiel Ego-Structure Test

LSI (Life style index) - Life Style Index

MDMQ (Melbourne decision making questionnaire) - Melbourne Decision Making Questionnaire

MMPI (Minnesota Personality Inventory) - Minnesota Multiphasic Personality Inventory

MPS (Multidimensional perfectionism scale) - Multidimensional Perfectionism Scale

PHQ (Patient Health Questionnaire) - Patient Health Questionnaire

SCL-90-R (Symptom Check List Revised) - Symptom Checklist-90-Revised

ShARS (Sheehan Anxiety Scale) - Sheehan Anxiety Scale

STAI (State-Trait Anxiety Inventory) - State-Trait Anxiety Inventory

**the drug is included in the list of Vital and Essential Drugs

# - the given disease or disorder is not indicated in the instructions for use

Terms and Definitions

Anxiety is a negatively valenced emotion expressing a sense of uncertainty, anticipation of negative events, and hard-to-define presentiments. 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.

A panic attack (panic) is a discrete short-term episode of intense anxiety with a sudden onset, reaching a peak within a few minutes, accompanied by distress and/or fear of dying or losing control, combined with pronounced somatovegetative symptoms.

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

Psychotherapy is a system of therapeutic intervention targeting the human psyche, and through the psyche and by means of it, the entire human organism.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Panic disorder (PD) (episodic paroxysmal anxiety) is one of the most common mental disorders, manifested by recurrent panic attacks that often occur spontaneously and unpredictably for the patient, without connection to specific situations, concrete objects, physical exertion, or life-threatening situations, while anticipatory anxiety—the fear of waiting for an attack—develops quite rapidly [1,2,3].

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

Risk factors for the development of panic disorder (PD) include [2,3,4]:

Personality traits—general negative affectivity, a tendency to experience negative emotions, and anxiety sensitivity (a predisposition to negatively evaluate various manifestations of anxiety and hold beliefs about their negative health consequences). A separate factor considered is the tendency toward anxious rumination and dwelling on panic, although their degree of risk in the development of PD has not yet been determined. A history of short-term fear episodes (time-limited panic episodes not meeting the criteria for PD) may be a risk factor for the manifestation of a panic attack (PA) and PD. Pronounced childhood separation anxiety is frequently found in patients with PD, but is not considered an independent predictor of PD [2,5,6,7,8].

Social factors—a history of childhood maltreatment, sexual abuse, and physical abuse is more common in patients with PD than in those with other anxiety disorders. Studies indicate that children raised by mothers suffering from PD are more likely to suffer from this disorder compared to patients whose mothers did not have PD. To date, it remains unclear whether this fact reflects the influence of genetic factors, anxiety proneness as a result of upbringing, or a combination of both. Smoking is considered a risk factor for both PA and PD. Many patients note the presence of specific stressful situations preceding the first PA (interpersonal difficulties, physical ailments, side effects of medications, general anesthesia, illness or death of a family member); in some cases, this connection is established during psychotherapy [2,9,10].

Genetic and physiological factors—PD is classified as a polygenic multifactorial disease, and genetic polymorphisms (multiple genetic variants) responsible for the manifestation of PD are actively being studied. There is an increased risk of developing PD if parents suffer from anxiety, depressive, or bipolar disorders. Modern neurobiological studies indicate a special role for the amygdala and its related structures in PD. The significance of structural and functional anomalies of the limbic system, basal ganglia, brainstem, temporal cortex, and prefrontal cortex is being considered. Respiratory pathology, such as asthma, is associated with PD at the level of medical history, comorbidity, and family history [2,11,12,13,14,15,16].

PD is currently the most thoroughly studied among anxiety disorders; nevertheless, there is no unified concept of the etiopathogenesis of this pathology. Popular theories include the autonomic theory, which is based on the study of cardiac parameters of sympathetic-parasympathetic interaction and responses to noradrenergic agents. Existing data confirm that PD may develop as a result of dysfunction or impaired interaction between the sympathetic and parasympathetic divisions of the autonomic nervous system. Another popular theory is the serotonergic theory, which is further supported by a good therapeutic response to serotonergic drugs. Close interactions between the serotonergic and other neurotransmitter systems, especially the noradrenergic system, when dysfunctional, can lead to autonomic regulation disorders and the manifestation of PD. The role of impairments in GABAergic transmission and the brain orexin system is currently being studied [2,16,17,18,19,20,21,22].

Neuroendocrine aspects of pathogenesis are also considered in the development of PD; the functioning of the body's hormonal systems, as well as the level and dynamics of cortisol, prolactin, estrogen, and thyroid-stimulating hormone (TSH), are of significance [20,23,24,25].

There are a number of theories that, while acknowledging the essential role of biological factors, identify psychological factors as the cause of PD. The most popular is the cognitive theory. It indicates that patients with PD have specific personality characteristics: increased anxiety sensitivity and a lowered interoceptive threshold, a tendency toward a catastrophic thinking style, and a drive for hypercontrol. This theory is supported by experiments in which such individuals report a significantly greater number of symptoms when provoked by physical exertion. The psychodynamic approach indicates that the experience of emotional deprivation from a significant other who embodies safety, coupled with a lack of stable attachment in early childhood, leads to deficits in personality structure that determine problems in the differentiation of mental and somatic sensations and the regulation of affective tension, which creates a predisposition for the manifestation of PD [2,3].

1.3 Epidemiology of the Disease or Condition

PD is most commonly diagnosed between the ages of 25 and 64, with data from most epidemiological studies showing a 2- to 4-fold female predominance over males. The prevalence of this disorder in the general population ranges from 2% to 5% according to various studies [26,27,28,29,30,31,32]. In the Russian Federation, PD is diagnosed relatively more frequently than abroad, particularly in European countries [182].

1.4 Features of Coding the Disease or Condition

F41.0 - Panic disorder [episodic paroxysmal anxiety]

F41.00 - Moderate panic disorder - at least 4 panic attacks in a four-week period

F41.01 - Severe panic disorder - at least four panic attacks per week over a four-week observation period

1.5 Classification of the disease or condition

Classification of PD (clinical) [1,2,33,34]:

1. PD with agoraphobia

2. PD without agoraphobia

1.6 Clinical presentation of the disease or condition

In the clinical picture of PD, of paramount importance are the periodic occurrence of panic attacks of varying intensity, the fear and anticipatory anxiety of new attacks, and a high likelihood of developing avoidant behavior [1,2,3,34].

Typical presentation of an attack [1,2,34,35,36,37,38]:

A characteristic onset with cardiovascular symptoms: a sudden onset of "palpitations", a sensation of skipped beats, "cardiac arrest", discomfort, or pain in the precordial region. Most panic attacks are accompanied by an increase in blood pressure (BP), which can reach quite high levels. As the intensity of the PA decreases, the BP levels drop in parallel with the resolution of fear, which can serve as a reliable diagnostic criterion in the differential diagnosis between essential hypertension with crises and panic disorder.

The most pronounced respiratory disturbances: labored breathing, a feeling of air hunger with dyspnea and hyperventilation, and a "feeling of suffocation". Describing the attack, patients report that "the throat was constricted", "air stopped coming in", "it became stuffy". It is these sensations that compel the patient to open windows, go out on the balcony, and seek "fresh air". An attack may begin with a sensation of suffocation, in which case the fear of death arises as a consequence of "impaired" breathing.

Gastrointestinal disorders such as nausea, vomiting, eructation, and epigastric discomfort are less commonly observed.

Typically, during a PA, patients experience dizziness, sweating, tremors with chills, waves of heat and cold, paresthesias, and coldness in the hands and feet.

Polyuria and/or frequent loose stools may occur in the concluding stage of the attack.

Objective findings include changes in facial flush, pulse rate, and blood pressure fluctuations, with dissociation frequently observed between the patients' subjective experience of autonomic disturbances and their severity during physical examination [1,2,33,35,38].

The key difference between PD and isolated PAs is the development of anticipatory anxiety regarding a new PA and, consequently, safety-seeking (avoidant) behavior, i.e., avoiding places and situations where a PA has previously occurred (e.g., public transport, crowds, etc.) [1,2,33,34,36].

Table 1.

Characteristic symptom manifestations in panic disorder:

Secondary disorders [2,34,39,40,41,42,43]:

• secondary fear of death, loss of self-control, and insanity;

• secondary avoidance of any situation in which the PA first occurred;

• secondary fears of being alone, of crowded places, and of recurrent PAs;

• secondary social phobias;

• secondary hypochondriacal disorders;

• secondary depressive disorders;

• secondary alcohol abuse (with an anxiolytic purpose);

• secondary dependence on sedatives;

Types of panic attacks:

a) by symptom presentation:

• major (full-blown) panic attacks — 4 or more symptoms;

• minor (pauci-symptomatic) — fewer than 4 symptoms;

Major attacks occur less frequently than minor ones (1 time/month to week), whereas minor attacks can occur up to several times a day.

b) by the prominence of specific components;

Table 2.

Types of attacks in PD

Course of PD:

As the disorder progresses, in "classic" cases, the following dynamics of PD are typical, usually passing through these stages:

• pauci-symptomatic attacks,

• full-blown panic attacks,

• hypochondria,

• limited phobic avoidance,

• extensive phobic avoidance, secondary depression.

The disease can develop slowly over months and years, or rapidly within days or weeks. In 50% of cases, panic disorder begins with stage 1, and in 50% with stage 2 [2,34,36,39].

As panic attacks continue, they may become associated with various life circumstances, which act as conditioned phobic triggers. Once panic attacks occur, they tend to become established and repeat in similar situations (crowded places, public transport, etc.). Patients develop anxious anticipation regarding the possibility of recurring attacks (anticipatory anxiety). A persistent feeling of fear is often formed after the very first paroxysm and relates to the situation in which it occurred (subway, bus, crowd). If an attack happens at home, alone, the fear of staying home alone often appears. This contributes to the development of a specific restrictive behavioral pattern, the so-called avoidance behavior or phobic behavior, which originates from the situation of the past attack and contributes to the development of agoraphobia. According to ICD-10, the diagnosis in this case is established as "panic disorder with agoraphobia".

Three "subtypes" of the course of panic disorder are distinguished [2,34,39]:

1. Only panic attacks are present, the clinical picture of which expands solely due to secondary transient hypochondriacal phobias and agoraphobia. Upon the resolution of the acute period and the reduction of panic attacks, a complete reversal of all psychopathological disorders also occurs.

2. Agoraphobia quickly joins the attacks and is distinguished by the persistence of its manifestations. Phobophobia and avoidance behavior form rapidly. As panic attacks regress, no reduction of other psychopathological disorders occurs. Agoraphobia comes to the forefront in the clinical picture and acquires a persistent character independent of the attacks. The elimination of the conditions causing these attacks (a restrictive lifestyle) becomes the main idea that governs the patients' entire lifestyle.

3. Characterized by the development of hypochondriacal phobias against the background of panic attacks. After the stage of full-blown attacks, cardio-, stroke-, and thanatophobia come to the forefront, determining the clinical picture for months and even years. There is constant interoceptive vigilance and hypochondriacal preoccupation with one's health, while even the most minor deviations in bodily function can trigger an exacerbation of phobias. At the same time, agoraphobia and restrictive behavior are absent.

Cognitive impairments are frequently encountered in anxiety disorders. They include: 1) impairments of attention and executive functions; 2) memory disorders, difficulties with memorization caused by attention impairment; cognitive and metacognitive deficit and vulnerability.

Attention impairment: 1) negative selective perception — heightened attention to threatening stimuli, leading to them being detected faster than neutral stimuli; 2) difficulties in shifting attention;

Memory impairment — positive experience of overcoming a situation is not consolidated. A crucial cognitive factor in the development of anxiety disorders is intolerance of uncertainty and catastrophic interpretation of somatic sensations [43,44,45].

Panic disorder has a high comorbidity with affective disorders, predominantly depressive disorders, bipolar disorder, suicidal behavior, alcohol dependence and psychoactive substance abuse, somatic diseases of the cardiovascular system, respiratory disorders, and neurological diseases [34,46,47,48,49,50,51,52,53,54,55,56,57].

• It is recommended to differentiate panic disorder from the following disorders [2,3,34,67,68,69,70,71,72,73,74,254]:

- social phobia;

- specific phobia;

- obsessive-compulsive disorder;

- post-traumatic stress disorder;

- generalized anxiety disorder;

- affective mood disorders (major depressive disorder, recurrent depressive disorder, bipolar affective disorder, dysthymia);

- somatoform disorders;

- schizophrenia (episodic with progressive deficit, sluggish), schizotypal disorder;

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

- epilepsy;

- residual-organic brain diseases;

- organic brain diseases;

- hypothalamic disorder;

- thyroid pathology;

- pheochromocytoma;

- arterial hypertension;

- cardiac arrhythmias;

- mitral valve prolapse;

- coronary artery disease;

- respiratory disorders;

- psychoactive substance use (e.g., amphetamines, cocaine, etc.);

- benzodiazepine withdrawal;

- side effects of pharmacotherapy (for example, systemic corticosteroids, sex hormones and modulators of sexual organ functions, psychostimulants, agents used for attention deficit hyperactivity disorder, nootropics, and heart disease medications).

RG CLE 5Recommendation Grade C (Level of Evidence 5).

2. Diagnostics, medical indications and contraindications for diagnostic methods

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

A. Recurrent panic attacks that are not restricted to any particular situation or set of circumstances and are therefore unpredictable (these episodes are unpredictable). Panic attacks are not associated with marked exertion or with a manifestation of danger or threat to life.

B. A panic attack is characterized by all of the following features:

1) it is a discrete period of intense fear or discomfort;

2) it starts abruptly;

3) it reaches a maximum within several minutes and lasts for at least several minutes;

4) at least 4 symptoms from the list below must be present, one of which must be from the list a-d:

Autonomic symptoms

a) palpitations or pounding heart;

b) sweating;

c) trembling or shaking;

d) dry mouth (not due to medication or dehydration); Symptoms related to the body:

e) difficulty breathing;

f) feeling of choking;

g) chest pain or discomfort;

h) nausea or abdominal distress (e.g., burning in the stomach, diarrhea, flatulence);

Mental status symptoms:

i) feeling dizzy, unsteady, lightheaded, or faint;

j) feelings that objects are unreal (derealization) or that one's self is distant or "not really here" (depersonalization);

k) fear of losing control, going crazy;

l) fear of dying;

General symptoms:

m) hot flushes or chills;

n) numbness or tingling sensations.

C. Most commonly used exclusion criteria. Panic attacks are not attributable to a physical disorder, organic mental disorder (F00-F09), or other mental disorder such as schizophrenia and related disorders (F20-F29), (affective) mood disorders (F30-F39), or somatoform disorders (F45-).

The range of individual variations in both content and severity is so vast that, if desired, two degrees—moderate and severe—can be distinguished using the fifth character:

F41.00 — Panic disorder, moderate severity, at least 4 panic attacks in a four-week period;

F41.01 — Panic disorder, severe, at least four panic attacks per week over a four-week observation period.

2.1 Complaints and Anamnesis

• When interviewing patients complaining of anxiety, it is recommended to identify the presence of discrete episodes of uncontrolled anxiety or panic that are not linked to specific situations, in order to verify the diagnosis [1,2,34,58,59,254].

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

• When taking the medical history of patients with episodic (paroxysmal) anxiety, it is recommended to identify the presence of panic and anxiety disorders in first-degree relatives and probands, as well as manifestations of overanxiety and overprotection by the patient's parents, for the purpose of differential diagnosis [2,34,59,60,61,62,63,254].

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

• When interviewing a patient with episodic (paroxysmal) anxiety, it is recommended to single out complaints related to autonomic manifestations of anxiety accompanying panic attacks (rapid heartbeat, sweating, chills, tremors, feeling of lacking air, weakness, dizziness, itching, numbness in the extremities, chest pain or stomach discomfort, nausea) in order to assess their condition and select therapy [1,2,3,34,62,63,64,65,66,67,254].

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

Comments: if the clinical symptoms differ from typical ones (as specified in ICD-10), a detailed differential diagnosis should be performed.

• When taking the medical history of all patients with panic attacks, it is recommended to identify the presence and assess the severity and intensity of avoidant/restrictive behavior in order to determine impairments in social functioning and the degree of quality-of-life reduction, as well as to develop an individualized psychotherapeutic strategy [1,2,3,34,62,63,64,65,66,67,254].

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

• When taking the medical history of all patients, it is recommended to identify previously established diagnoses or signs and symptoms of somatic diseases that may present with conditions similar to panic attacks (coronary artery disease, epilepsy, bronchial asthma, pheochromocytoma, hyperthyroidism, arterial hypertension, hypoglycemic states, etc.) for the purpose of differential diagnosis of panic disorder [1,2,34,64,66,67].

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

• When taking the medical history of all patients with panic disorder, it is recommended to assess suicide risk in order to determine the type and scope of psychiatric care required [1,2,34,64,66,67,254,256].

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

• When taking the medical history of all patients, it is recommended to identify episodes of substance or alcohol abuse and a history of taking any medications for the purpose of differential diagnosis between panic disorder and substance-induced disorders [1,2,34,64,66,67].

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

• When taking the medical history and clarifying the complaints of all patients with anxiety, it is recommended to identify the presence of other mental disorders (aside from panic disorder), particularly post-traumatic stress disorder, depression, and bipolar disorder, for the purpose of differential diagnosis of panic disorder [1,2,34,64,66,67].

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

Comments: Panic attacks frequently occur within the framework of other mental disorders distinct from panic disorder. If post-traumatic stress disorder, depression, or bipolar disorder is identified, it is more appropriate to assess panic attacks in these patients as symptoms of the aforementioned conditions.

2.2 Physical Examination

• All patients with episodic (paroxysmal) anxiety are recommended to undergo a physical examination, external inspection, measurement of height, body weight, physical development level, and skin integrity in order to rule out somatic diseases, detect signs of self-harm including cutting scars (taking into account their age), assess somatic status, etc. [2,34,57,59,68]

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

• All patients with episodic (paroxysmal) anxiety are recommended to undergo a standard physical and neurological examination to rule out somatic and neurological causes of autonomic symptoms [2,33,39,57,58,65].

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

• For all patients with episodic (paroxysmal) anxiety, the physical examination is recommended to include an inspection of the scalp to detect scars from previous injuries, and an inspection of the oral mucosa and tongue (scars, bite marks) for the purpose of differential diagnosis with epilepsy, traumatic brain injury, and syncopal episodes [2,33,39,57,58,65,68].

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

• For all patients with episodic (paroxysmal) anxiety, the physical examination is recommended to include the detection of injection marks of varying ages in order to identify psychoactive substance use [2,34,57,59,68].

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

• All patients with episodic (paroxysmal) anxiety are recommended to undergo thyroid palpation and have the absence of exophthalmos verified to rule out thyroid disorders [2,34,57,59,68]

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

• All patients with episodic (paroxysmal) anxiety are recommended to have their pulse and blood pressure measured in the supine position (after resting for 5 minutes) and standing position (3 minutes after standing up) to assess autonomic manifestations and somatic status [2,22,34,57,59,68]

RG CLE 5Recommendation Grade C (Level of Evidence 5).

2.3 Laboratory Diagnostics

There are no specific laboratory diagnostic methods for panic disorder. Laboratory tests are used to rule out other symptomatically similar pathologies.

• All patients with panic disorder are recommended to undergo a general (clinical) urinalysis, a complete blood count with assessment of hemoglobin and hematocrit levels, red blood cell, leukocyte, and platelet counts, and erythrocyte sedimentation rate as part of the initial examination, upon admission to the inpatient facility, and during follow-up monitoring to clarify the degree of disease activity and diagnose involvement of organs and systems [2,34,57,59,68].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

• All patients with panic disorder are recommended to undergo a general biochemical blood test (assessment of potassium, sodium, chloride, glucose, creatinine, total protein, urea, uric acid, total bilirubin, direct and indirect bilirubin, aspartate aminotransferase and alanine aminotransferase activities, C-reactive protein) as part of the initial examination, upon admission to the inpatient facility, and during follow-up monitoring to assess renal and hepatic function and rule out inflammation [2,34,57,59,68].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

• All patients with panic disorder are recommended to undergo blood testing for Hepatitis B virus surface antigen (HbsAg), antibodies to Hepatitis C virus, antibodies to Treponema pallidum, IgM and IgG antibodies to Human immunodeficiency virus HIV-1, and IgM and IgG antibodies to Human immunodeficiency virus HIV-2 as part of the initial examination, upon admission, and subsequently every 12 months to rule out association with HIV infection, hepatitis, or syphilis [2,34,57,59,68].

GCR CLOE 5Grade of Recommendation C (Level of Evidence 5).

• All patients with episodic (paroxysmal) anxiety are recommended to undergo blood tests to assess thyroid function: [2,14] determination of serum total triiodothyronine (T3) levels, serum free triiodothyronine (T3) levels, serum total thyroxine (T4) levels, serum free thyroxine (T4) levels, and blood thyroid-stimulating hormone levels to rule out thyroid pathology [2,34,57,59,68].

GCR CLOE 5Grade of Recommendation C (Level of Evidence 5).

2.4 Instrumental Diagnostics

• For all patients with episodic (paroxysmal) anxiety in whom history-taking, physical and neurological examination, and laboratory test results do not allow paroxysmal conditions to be ruled out with a high degree of certainty, electroencephalography is recommended to assess brain bioelectric potentials and rule out such pathology [2,34,57,59,68].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

• For patients with episodic (paroxysmal) anxiety who have a history of syncopal episodes, and for individuals in whom history-taking, physical and neurological examination, and laboratory test results do not allow cerebrovascular disorders to be ruled out with a high degree of certainty, transcranial duplex scanning of arteries and veins is recommended to rule out such pathology [2,34,57,59,68]

RG CLE 5Recommendation Grade C (Level of Evidence 5).

• For patients with episodic (paroxysmal) anxiety who have a history of traumatic brain injury, suspected brain neoplasms, headaches, and those in whom history-taking, physical and neurological examination, and laboratory test results do not allow organic brain damage to be ruled out with a high degree of certainty, magnetic resonance imaging (MRI) of the brain is recommended to rule out such pathology [2,34,57,59,68]

RG CLE 5Recommendation Grade C (Level of Evidence 5).

• All patients with episodic (paroxysmal) anxiety are recommended to undergo electrocardiography to assess somatic status and rule out cardiovascular pathology [2,34,57,59,68,70,71]

RG CLE 5Recommendation Grade C (Level of Evidence 5).

2.5 Other Procedures

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

PD is a disorder whose pathogenesis and clinical (clinico-psychopathological and clinico-psychological) manifestations are heavily influenced by psychological factors, with psychotherapy being 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 preserved and impaired individual psychological features caused by 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 important components of a medical psychologist's participation in providing medical care to patients with PD is psychological diagnostics. All main types, methods, and techniques adopted both in psychological diagnostics in general and in its applied clinical branch, referred to as "medical psychodiagnostics" or "clinical psychological diagnostics," are utilized. In accordance with the basic theoretical principles of psychological diagnostics, clinical practice employs both clinico-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 reflect to a greater extent the individual psychological features of the personality itself and its preservation/alteration in the situation of illness, as well as reveal a wide range of connections, attitudes, ways of coping and reacting inherent in the subject, other clinically significant personality characteristics and personality-environment interaction, etc. Such data should be evaluated within the framework of a personalized approach in implementing the biopsychosocial paradigm of modern anthropocentric and clinical sciences. At the same time, clinical methods are organically woven into the experimental-psychological research procedures and are used directly in the process of the subject performing tests and testing techniques. A distinctive feature of applying clinical and experimental-psychological methods in solving psychological diagnostic tasks is the consideration and analysis of the specifics caused by the illness-altered mental and psychological status of the subject.

Thus, when conducting a psychodiagnostic examination of a patient with panic disorder within the framework of a clinical and psychological psychodiagnostic study, the following are applied:

1. Clinical rating scales;

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

• In all patients with panic disorder, it is recommended to use the Panic Disorder Severity Scale (PDSS) to assess symptom severity (Appendix G 2) [252,255,256].

GGR BLEL 3Grade of Recommendation B (Level of Evidence 3).

Comments: in patients with episodic (paroxysmal) anxiety, it is necessary to use psychometric scales and symptom questionnaires for screening and assessing the level of anxiety and its dynamics, the choice and scope of which are determined individually depending on the clinical presentation of the disorder, diagnostic and therapeutic objectives: Questionnaire for identifying signs of autonomic changes — Wayne's Scale (Appendix G1); Panic Screening Questions (PHQ) (Appendix G3); The Hamilton Anxiety Rating Scale (HARS) (Appendix G4); Symptom Check List-90-Revised (SCL-90-R) (Appendix G5); Integrative Anxiety Test (IAT) (Appendix G6); State-Trait Anxiety Inventory

- Spielberger State-Trait Anxiety Inventory (STAI) (Appendix G7); The Beck Anxiety Inventory

- Beck Anxiety Inventory (BAI) (Appendix G8); Sheehan Patient-Rated Anxiety Scale (ShARS) (Appendix G9) [1,2,3,34].

The aforementioned methods are psychometric and/or symptom questionnaires that allow an objective assessment of the nature and severity of clinical symptoms, as well as their dynamics.

A more comprehensive psychological assessment is carried out by a medical psychologist depending on specific diagnostic tasks or to determine the targets of psychotherapeutic intervention. An experimental-psychological examination is ordered by the attending physician. 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 psychological report. The choice of methods for experimental-psychological diagnostics is made by the medical psychologist individually, depending on the tasks addressed regarding a specific patient. Various scales adapted and validated depending on the goals of the study may be used [195,196,197]. The methods suggested below are applied optionally, and the list of possible methods for conducting an experimental-psychological examination is not limited to them.

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 G10) [2,34,183]; Ich-Struktur-Test nach G. Ammon — G. Ammon's Ego-Structure Test (ISTA) (1978) (Appendix G11) [2,34,184].

The most frequently used methods for studying individual psychological characteristics of personality: Method for determining the level of subjective control (LSC) (Appendix G12) [2,22,185]; Personal Beliefs Test (Kassinove H., Berger A., 1988) (Appendix G13) [2,22,186]

The most frequently used methods for psychological diagnosis of risk factors for mental maladaptation: Life Style Index (LSI) (Appendix G14) [2, 34, 187]; Ways of Coping Questionnaire by R. Lazarus (WCQ, Folkman S., Lazarus R., 1988) (Appendix G15) [2,34, 188]; Melbourne Decision Making Questionnaire (MDMQ) (Appendix G16) [2,34,189]; Experiences in Close Relationships-Revised (ECR-R) questionnaire by Brennan and R.C. Fraley (adapted by T.V. Kazantseva, 2008) (Appendix G19); Adverse Childhood Experiences (ACE) questionnaire (Anda R.F., Felitti V.J., 1998, 2004) (Appendix G20);

The most frequently used methods for psychological diagnostics of the system of significant relations: Neurotic Personality Questionnaire KON-2006 (Aleksandrowicz J. et al., 2006) (Appendix G17) [2,34,190].

To assess treatment adherence, the following method is used: Russian Universal Quantitative Treatment Adherence Questionnaire (KOP-25) (Appendix G18) [2,34, 191].

Psychological diagnostics is performed by a medical psychologist according to the following algorithm [195,196,197,198]:

Stage 1 — Clinical and psychological examination aimed at establishing a trusting rapport, 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 experimental-psychological examination (EPE) report: rapport, attitude toward the examination, understanding of instructions, interest in testing results, speech volume and rate, facial expressions, general emotional background, pace of psychomotor reactions, behavioral characteristics during the examination, and personality traits demonstrated by the patient.

Stage 2 — Experimental-psychological examination (EPE). The objectives of the experimental-psychological examination are: differential diagnosis of disorders in the patient's mental activity;

- analysis of the structure and determination of the degree of impairment of mental processes, states, and personality traits;

- determination of the development level of psychological adaptive potential, and 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 examination, higher mental (cognitive) functions, as well as the patient's personal and emotional spheres, are studied, and a qualified expert assessment of the identified disorders is performed. Based on the results of the EPE, an expert report is drawn up (Appendix G21), and the expert psychologist provides recommendations that must be taken into account by medical specialists in the therapeutic process [195,196,197].

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) [199,200,201].

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

Data from modern scientific research confirm the high efficacy of both certain antidepressants and anxiolytics, as well as psychotherapy (cognitive-behavioral, dynamic, relaxation, etc.). There are studies showing high efficacy of the combined use of psychopharmacotherapy and psychotherapy. The choice of therapeutic strategy and the ratio of psychopharmacotherapy to psychotherapy depend on the clinical manifestations, the stage of treatment, personality traits, patient attitudes and expectations, current resources, and organizational capabilities, and should be flexibly evaluated taking a personalized approach in each specific case. There are indications and contraindications for both psychopharmacological and psychotherapeutic treatment. These are predominantly associated with the patient's condition, side effects, and organizational conditions [75,76,77,78,79,80,81,82,83,202].

• In all patients with panic disorder, the use of psychopharmacotherapy and/or psychotherapy is recommended to relieve symptoms [75,76,77,78,79,80,81,82,83].

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

Comments: the advantages of psychotherapy include the absence of somatic side effects and, according to some studies, better preservation of the achieved results [77,79,80,82]. The disadvantages are high cost, the need for weekly visits, and the critical importance of personal motivation and patient engagement in the treatment process. Psychopharmacotherapy requires fewer financial and time resources, but quite often causes side effects, and discontinuation may lead to symptom relapse [77,79,80,82].

3.1. Psychopharmacotherapy

• In patients with an established diagnosis of panic disorder, it is recommended to initiate therapy with selective serotonin reuptake inhibitors or #venlafaxine [76,86,202,258,259,260] to reduce general anxiety, frequency, and intensity of panic attacks (the efficacy of #fluvoxamine [108,109], citalopram [98,99], escitalopram [98,99], paroxetine** [76,86,100,102,103], #fluoxetine* [76,86,111], venlafaxine [108,109] has been proven).

LeR ALoE 1Level of Evidence A (Level of Confidence of Evidence 1).

Comments: since RCTs conducted to evaluate the efficacy of drugs in the treatment of PD did not take into account the clinical variant and seizure types, there are certain difficulties in applying their results when implementing a personalized approach in medicine. After establishing the diagnosis, as a first-line course, it is advisable to prescribe drugs from the group of selective serotonin reuptake inhibitors or venlafaxine. Recommended dosages: escitalopram - 5 mg/day starting dose, 10-20 mg/day - maintenance; paroxetine** - start with 10 mg with weekly increases of 10 mg/day up to 40-60 mg/day; #fluoxetine** - 20-60 mg/day [76]; citalopram - 20-60 mg/day; sertraline** - 50-200 mg/day; #fluvoxamine - 100-300 mg/day; venlafaxine - 75-225 mg/day. It is important to note that #venlafaxine is characterized by a slightly worse tolerability and side effect profile than selective serotonin reuptake inhibitors (primarily a possible increase in blood pressure, which is not characteristic of selective serotonin reuptake inhibitors) [75,76,78,84,85,88,89,91,93]. The 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. For all the above drugs, an oral route of administration is recommended, with a treatment duration of 6-12 months [75,76,84,85,88,91,93]. It is undesirable to prescribe amitriptyline in elderly patients. Therapy with these drugs starts with minimum 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 in case of frequent panic attacks [83,84,85,86,87,88,89,90,91,92,92,94,95,96,97]. The advantages of antidepressants include a good 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 beginning of administration, the need for dosage titration, and a negative impact on sexual function; it is recommended to warn the patient about the possible development of side effects at the beginning of antidepressant administration to ensure compliance. In the first weeks of administration, it is advisable to observe the patient, assessing suicide risks and possible intensification of anxiety symptoms. When prescribing pharmacotherapy, the physician relies primarily on evidence of the drug's proven efficacy, its tolerability profile, as well as the physician's own clinical experience and qualification [72,77,194].

• For panic disorder patients without contraindications, it is recommended to prescribe benzodiazepine derivatives for a short course (up to 3–4 weeks) to reduce anxiety levels and the frequency of panic attacks: clonazepam** 0.25–4 mg/day, lorazepam** 1–6 mg/day, alprazolam 0.75–6 mg/day, diazepam** 5–10 mg/day [76,86,103,115,116,117,118,119].

GGR BLEL 3Grade of Recommendation B (Level of Evidence 3).

Comments: the advantages of benzodiazepine derivatives include a rapid effect, good tolerability, a wide therapeutic window, and safety in overdose; a thorough substance abuse history must be obtained prior to prescribing this group of drugs. It is inappropriate to prescribe them to patients with substance use disorders or a risk of developing such dependence. They are also not recommended for elderly patients due to an increased risk of coordination disorders and falls. Attention should be paid to patient compliance—in some cases, patients are prone to exceeding recommended dosages. Benzodiazepine derivatives can cause dependence and are associated with a withdrawal syndrome upon sudden cessation of therapy. Therefore, the duration of their use should be limited to 3–4 weeks. When used in combination therapy with antidepressants, it is preferable to prescribe them for the first weeks of therapy until the antidepressants take full effect, and then discontinue them. Longer-term therapy with benzodiazepine derivatives is possible in cases of resistance to other types of therapy. Adverse events most commonly reported include sedation, dizziness, impaired coordination, impaired concentration, memory impairment, and the development of dependence and tolerance. There are no evidentiary studies on the efficacy of bromdihydrochlorophenylbenzodiazepine. However, in Russian medical practice, it is traditionally used to treat anxiety disorders and abort panic attacks [1]. When prescribing benzodiazepines, their half-life should be taken into account when deciding on the frequency of administration. For example, due to its relatively short half-life, alprazolam should be prescribed at least 3 times a day. The route of administration is oral; in cases of severe symptoms, intramuscular and intravenous routes are permitted [75,76,83, 85,86,88,92,95].

• For panic disorder patients, to abort panic attacks, it is recommended to intermittently ("as needed") prescribe benzodiazepine derivatives (clonazepam*[*] 0.25–4 mg/day, lorazepam** 2–7.5 mg/day, alprazolam 0.75–6 mg/day, diazepam** 5–10 mg/day) [76,86,103,115,116,117,118,119,120,121,202].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

Comments: the advantages of benzodiazepine derivatives are their rapid onset of action, which ensures quick relief of panic attacks and stabilization of the condition. However, according to some studies, prescribing benzodiazepines "as needed" may not be a fully effective and safe strategy [88,92,95]. This phenomenon can be explained both by patients inappropriately increasing the dose themselves out of fear of a panic attack and by sharp fluctuations in plasma drug concentrations. In addition, taking benzodiazepine derivatives "as needed" can become a specific form of safety-seeking behavior for patients: they carry the medications "just in case" and may take them at the suspicion of an oncoming panic attack.

• In patients whose psychopharmacotherapy with selective serotonin reuptake inhibitors or venlafaxine has led to partial but not complete relief of panic disorder symptoms, it is recommended to increase the dose of antidepressants to the maximum recommended dose in order to completely resolve panic disorder symptoms [75,83,84,85,86].

GCR CGrade of Recommendation C (Level of Evidence).

• For panic disorder patients with an inadequate response to ongoing therapy, it is recommended to switch the antidepressant after 4–6 weeks or use combination treatment regimens combining antidepressants and anxiolytics or antidepressants and antipsychotics, as well as combining psychopharmacotherapy and psychotherapy to overcome resistance [75,76,78,80,86,129,130,131,132,133,134,135].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

• For patients with panic disorder, it is recommended to conduct dynamic assessments using the Hamilton Anxiety Rating Scale (HARS) to evaluate the efficacy of the ongoing treatment [75,76,78,80,86,129,130,131,132,133,134,135]

RG CLE 5Recommendation Grade C (Level of Evidence 5).

Comments: response to therapy is defined as a reduction in the total Hamilton Anxiety Rating Scale score of > 50%, and remission as a score of < 7 (Hamilton Anxiety Rating Scale, abbr. HARS;

In practice, it is useful to distinguish three levels of therapeutic response efficacy:

1. Treatment is effective, complete response—complete absence of panic attacks.

2. Treatment is effective, partial response—the frequency of panic attacks is reduced by at least 50%.

3. Treatment is ineffective—the frequency of panic attacks has not changed or has decreased by less than 50%.

The levels outlined above are guideline estimates and should be considered alongside the physician's overall clinical impression, which includes assessing the severity of agoraphobic symptoms (anticipatory anxiety and avoidance behavior), the severity of panic attacks (number of symptoms per attack), and the degree of the patient's social maladaptation.

• For all patients who do not show a sufficient response to a particular psychopharmacological agent, it is recommended to verify patient compliance in order to confirm the fact of an inadequate therapeutic response to the drug [1,2,75,84,85,88,91,93].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

Comments: in case of initial therapy failure, it is first necessary to ensure that the patient is compliant, as non-adherence to the medication regimen is a cause of treatment resistance in a significant number of cases [75,76,85,86,93]. Treatment non-adherence may be related to side effects, insufficient patient understanding of the need to follow prescriptions, the perception that the treatment is ineffective (especially with antidepressants, which have a delayed onset), and lack of attention to treatment. To improve compliance, potential side effects should be discussed with the patient, the importance of strictly adhering to the medication schedule explained, and the delayed onset of action of certain drugs clarified. If non-adherence is identified, the cause should be investigated and a problem-solving strategy developed jointly with the patient.

• In those patients whose psychopharmacotherapy with selective serotonin reuptake inhibitors or venlafaxine resulted in partial but not complete relief of panic disorder symptoms, it is recommended to add benzodiazepine derivatives for 3 weeks (if the patient did not receive benzodiazepines at the initial stage) in order to fully resolve panic disorder symptoms [86,88,93].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

Comments: Optimal drug dosages: alprazolam 0.75–6 mg/day; clonazepam** 1–4 mg/day; lorazepam** 2–7.5 mg/day; diazepam** 5–30 mg/day. Route of administration: oral; in severe symptoms, intramuscular and intravenous administration are permitted. Duration of therapy: up to 3 weeks [75,76,78,83,88,93].

• In patients who failed to achieve remission on initial therapy with selective serotonin reuptake inhibitors or venlafaxine, it is recommended to switch therapy to imipramine** or clomipramine** to relieve panic disorder symptoms [75,76,78,83,88,93].

GCR BLOE 1Grade of Recommendation B (Level of Evidence 1).

• In patients who failed to achieve remission on therapy with selective serotonin reuptake inhibitors, venlafaxine, imipramine**, or clomipramine**, it is recommended to use benzodiazepine monotherapy to relieve panic disorder symptoms [75,76,83,88,103,116,117, 121].

GCR BLOE 1Grade of Recommendation B (Level of Evidence 1).

Comments: Optimal drug dosages: alprazolam 0.75–6 mg/day; clonazepam** 1–4 mg/day; lorazepam** 2–7.5 mg/day; diazepam** 5–30 mg/day; bromdihydrochlorophenylbenzodiazepine** 1–6 mg/day. Route of administration: oral; in severe symptoms, intramuscular and intravenous administration are permitted. Duration of therapy: no more than 6 months. High risk of dependence development [75,76,86,103,115,116,117,118,120,121].

• All patients who have achieved remission on monotherapy with benzodiazepine derivatives are recommended to continue therapy for no more than 6 months as maintenance therapy to maintain PD remission [75,76,85,86,115,118,121].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

Comments: regarding benzodiazepine derivatives, general recommendations prescribe their use in short courses [75,76,85,86,88,93]. Therefore, for safety reasons, long-term administration of benzodiazepine derivatives (up to 6 months) may be justified only if antidepressant therapy is ineffective [88,92,95,115]. It is important to bear in mind that discontinuation of benzodiazepine derivatives must be carried out with a gradual dose reduction to mitigate the severity of withdrawal syndrome [76,116]. At the same time, drugs with a short half-life (alprazolam and lorazepam**) cause more pronounced withdrawal syndromes than drugs with a longer half-life (clonazepam**, diazepam**) [119,120,121].

• After the onset of a therapeutic effect, in order to stabilize the effect and prevent relapses, patients with PD are recommended to undergo long-term pharmacotherapy (at least 6 months) [75,76,85,86,88,92].

GCR BLOE 1Grade of Recommendation B (Level of Evidence 1).

Comments: according to some sources, the duration of ongoing therapy for relapse prevention is 12 months. Maintenance therapy should be carried out at the same dose at which the positive effect was achieved. It is important to note that upon completion of the therapy period, drug withdrawal should be performed with a gradual dose reduction and careful monitoring of the patient's condition for at least 2–3 months [75,76,85,86,88,93]. This recommendation is related to the potential occurrence of antidepressant discontinuation syndrome (ADS) upon abrupt cessation of antidepressants [203,204]. To avoid ADS or manage its manifestations if a decision is made to discontinue the antidepressant, the following algorithm for the prevention and management of patients with antidepressant discontinuation syndrome is proposed (Appendix B4) [203,205,206].

• In patients with PD receiving psychopharmacotherapy, it is recommended to evaluate the efficacy and tolerability of therapy on days 7, 14, and 28 of psychopharmacotherapy and subsequently 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 substitution is performed [75,76,85,86,88,92].

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

• In patients with PD undergoing psychopharmacotherapy, it is recommended to assess the following adverse effects: sedation, somnolence, lethargy, urinary retention, constipation or diarrhea, nausea, headaches, dizziness, sexual dysfunction, coordination impairment, concentration impairment, memory impairment, development of drug dependence and tolerance, etc., within the framework of a personalized approach to reduce the likelihood of side effects and complications from the therapy [75,76,85,86,88,92,209,253].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

Comments: at the same time, adequate dosages (Appendix A3, Table 1) and prescribing medications strictly according to indications significantly reduce the risk of adverse events.

• For patients who have failed to achieve remission on therapy with selective serotonin reuptake inhibitors, #venlafaxine, **imipramine, or **clomipramine, or benzodiazepine derivative monotherapy, with verified compliance and PD diagnosis, it is recommended to switch to treatment-resistant strategies in order to relieve PD symptoms [75,76,85,86,88,92].

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

Comments: for treatment-resistant cases of PD, the following drugs may be prescribed, for which there are a small number of open-label studies or case series (Level of Reliable Evidence - C; Level of Evidence - 5): antidepressants — #mirtazapine 15–30 mg/day [207,208], #duloxetine 60–120 mg/day [211]; anticonvulsants — #gabapentin 600–3600 mg/day [213,214], #valproic acid** 500–3000 mg/day [212,215,216]; addition of antipsychotics to antidepressants — #olanzapine** 2.5–20 mg/day [210,217], #risperidone** 0.25–3 mg/day [218], #aripiprazole 5–30 mg/day [219]. Oral administration is recommended for all the above-mentioned drugs; the duration of therapy was not specifically studied in trials and should be determined individually in each case depending on the patient's clinical condition [75,76,85,86,88,93]. The use of buspirone, propranolol**, and trazodone has proven ineffective in panic disorder [202].

3.2 Psychotherapy

Psychotherapy is a proven effective method for treating neurotic disorders, including panic disorder. A number of studies have demonstrated equal efficacy of psychotherapy and psychopharmacotherapy in PD. It should be noted that, overall, psychopharmacotherapy provides faster improvement and requires less patient effort, time, and financial cost, but symptoms may recur when medications are discontinued. Psychotherapy, especially when psychological mechanisms of PD formation and maintenance play a significant role, provides a higher-quality effect and more sustained remission. The optimal approach is a combination of psychopharmacotherapy and psychotherapy, as this maximally aligns with the modern biopsychosocial concept of mental disorders and makes it possible to implement the principles of personalized medicine and enhance the effectiveness of therapeutic interventions. Evidence-based studies exist for a number of psychotherapy methods. However, it must be kept in mind that the design of evidence-based studies in psychotherapy is quite complex, and clinical practice differs from scientific experiments in many respects. The large number of sources demonstrating the efficacy of cognitive behavioral therapy is likely related to the ability within scientific research to reproduce specific techniques rather than to an unconditional priority of this method for patients with panic disorder. Other psychotherapy methods, which currently have a smaller evidence base, may be no less effective—and potentially in certain cases more effective—than cognitive behavioral therapy [1,2,77,78,81,83,134,136,137,138,139,140,141,142,143,144,145,146].

Contraindications and limitations for psychotherapeutic treatment [2,78,83,137,142]:

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 cannot regularly attend psychotherapy sessions;

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 deriving benefit from this work (who constantly act out their emotions as a defense mechanism rather than observing their psychological state; or patients with severe negativism or rigidity);

• In the treatment of patients with PD, it is recommended to use various types of psychotherapy in combination with psychopharmacotherapy for more effective and sustained reduction of anxiety, frequency of panic attacks, learning relaxation, correcting irrational beliefs, and realizing deep-seated mechanisms and conflicts. The ratio of psychopharmacotherapy to psychotherapy is determined flexibly depending on individual clinical manifestations and the patient's psychological characteristics [1,2,77,78,81,83,134, 138, 142,145].

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

• In all patients with PD, except for those with intellectual disability, 10–15 sessions of cognitive behavioral therapy are recommended to reduce anxiety levels, decrease the frequency of panic attacks, and overcome restrictive behavior [2,77,78,147,148,149,150,151,152].

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

Comments: cognitive model of panic disorder. Patients with panic disorder tend to view any unexplained symptom or sensation as a sign of imminent catastrophe. The main trait of people with panic reactions is the conviction that their physiological systems — cardiovascular, respiratory, central nervous — will fail. Patients with panic disorders have a specific cognitive style: they are unable to realistically perceive their sensations and interpret them catastrophically.

The main targets of cognitive behavioral therapy are: low tolerance for uncertainty; positive beliefs about worry; lack of problem-solving orientation; cognitive avoidance.

Within cognitive behavioral psychotherapy, not all techniques have high efficacy. There are studies showing varying effectiveness of cognitive behavioral therapy techniques. Some studies note the ineffectiveness of muscle relaxation, which in certain cases may contribute to fixing the patient's attention on internal sensations.

Breathing training is traditionally used and is indicated in cases of a prominent hyperventilation component in the structure of panic attacks. Due to the fact that dyspnea occurs against the background of stress, which is assessed as health-threatening and provokes or enhances fear caused by external anxiety stimuli, breathing control training followed by cognitive reattribution of symptom meaning is recommended. The training can be supplemented with experimental hyperventilation with the acquisition of symptom control skills through breathing into a paper bag. Its effectiveness is not always evaluated unambiguously and largely depends on the clinical manifestations of panic disorder and the patient's attitudes. Interoceptive exposure—increasing tolerance to unpleasant internal sensations that occur in the patient during a panic attack—has a well-proven effect. Cognitive restructuring and decatastrophizing are aimed at correcting erroneous beliefs and interpretations of bodily sensations. It can be supplemented with in vivo exposure to obtain additional information that will disprove erroneous judgments. Exposure in real-life conditions does not always increase treatment effectiveness, but it can be useful for testing behavior in reality and increasing treatment adherence. Modern options for exposure include the active use of virtual reality capabilities for its delivery, such as special goggles. CBT can be carried out in both individual and group formats. The development of technical capabilities has contributed to the development of methods using virtual reality, internet technologies, and mobile applications. There are studies both confirming and refuting the effectiveness of virtual reality exposure. There is evidence that the use of remote CBT does not significantly reduce its effectiveness, and this technology can be used in the future.

The effectiveness of third-wave CBT methods is being confirmed: mindfulness-based cognitive therapy (MBCT) and mindfulness-based stress reduction (MBSR) techniques are used, including via the internet, for the treatment of panic disorder [2,78,152,153,154,155,156,157,158,159,160,161,162,220,221].

• For patients with panic disorder who have low tolerance to the perception of psychotraumatic stimuli, virtual reality exposure therapy is recommended in order to increase resilience to them [222,223,224,225,226,227,228,229,230].

Level of Evidence AGrade of Recommendation 1Level of Recommendation A (Level of Evidence — 1)

Comments: virtual reality allows for the correction of the patient's perception of psychotraumatic stimuli by immersing the patient in a multisensory virtual environment with a set of specially adapted (targeted) stimuli, which leads to a significant reduction in panic disorder symptoms. Game simulation of real triggers that cause panic attacks, with individual control of reactions to them, leads to an increase in the threshold of their psychosensory perception and the active participation of the patient in combined exposure and game psychotherapy. Procedures lasting 20-25 minutes are carried out daily or every other day, with a course of 10-15 procedures.

• For all patients with panic disorder, in order to reduce the severity of anxiety and associated behavioral and somatic symptoms, the use of Eye Movement Desensitization and Reprocessing (EMDR) is recommended as an adjunct method [231,232].

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

Comments: meta-analytic studies of randomized controlled trials show that EMDR is effective in reducing symptoms of anxiety, panic, and associated behavioral/somatic symptoms. However, the long-term efficacy of EMDR in panic disorder remains unclear, and there is no evidence supporting the efficacy of EMDR as a standalone treatment method for panic disorder. Patients with panic disorder are recommended to undergo short-term psychodynamic psychotherapy—24 sessions at a frequency of 2 times a week—to reduce the level of anxiety, decrease the frequency of panic attacks, and clarify the unconscious mechanisms underlying the symptoms [167,168,169,170,171].

• For patients with panic disorder who have specific parental representations, psychotraumatic situations, or difficulties in expressing and regulating feelings of anger and rage, short-term psychodynamic psychotherapy—24 sessions at a frequency of 2 times a week—is recommended to reduce anxiety levels, decrease panic attack frequency, and clarify unconscious mechanisms underlying the symptoms [167,168,169,170,171].

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

Comments: RCTs have confirmed the efficacy of using the psychodynamic approach in the treatment of PD (psychodynamic formulation for panic disorder PFPP), which was facilitated by the identification of symptomatic targets. This is a specific structured form of psychoanalytic psychotherapy focusing on panic symptoms and aspects of psychodynamics associated with panic manifestations. Efficacy in randomized studies. Treatment is aimed at identifying the meaning of panic symptoms, drawing attention to the manifestations of psychological defense mechanisms that suppress the awareness of denied feelings, conflicts, and fantasies associated with panic. Clarification, confrontation, and interpretation are used as the main techniques. The therapy has three phases, which do not necessarily follow each other and may have varying durations depending on the patient's characteristics. The first phase is aimed at identifying the specific content and meaning of panic episodes. The patient's medical history is analyzed to identify specific vulnerabilities that could have contributed to the manifestation of PD, such as specific parental representations, psychotraumatic situations, and difficulties in expressing and regulating feelings of anger and rage. The therapist in a neutral manner helps the patient verbalize unconscious or poorly tolerated fantasies and feelings, such as the fear of being abandoned or the desire for revenge. This information is used to formulate the intrapsychic conflict associated with anger, the development of personal autonomy, and sexuality. The main goal is the reduction of panic symptoms. The second phase aims to identify the psychodynamic components that determine vulnerability to the manifestation and maintenance of panic. The most common are conflictual experiences associated with the recognition and regulation of anger, contradictory experiences regarding dependency-autonomy with manifestations of separation anxiety, and conflicts associated with manifestations of sexual arousal. The dynamics of these relationships manifest both in the discussion of the patient's current relationships and with significant others in the past. In relationships with the therapist, these patients often reproduce in transference reactions their conflicts related to anger, separation, and independence. A better understanding of these conflicts helps break the vicious cycle associated with "panic about panic" and reduces vulnerability to panic symptoms. The termination phase provides an opportunity to work through conflicts associated with anger and autonomy as they manifest in the context of treatment termination and parting. The therapist helps the patient focus on experiencing and articulating feelings associated with loss specifically regarding the therapist. Better awareness and understanding promote successful regulation of these feelings and reduce the likelihood of severe PAs. The ability to express anger in a socially acceptable, fear-free form is an important achievement of therapy. Higher assertiveness and the ability to discuss interpersonal conflicts improve psychosocial functioning and reduce vulnerability to PAs [2,78,167,168,169,170,171,172,173,174,175].

• For all patients with panic disorder, in order to reduce anxiety levels, decrease panic attack frequency, and control breathing and muscle tension, the use of relaxation methods—10-15 sessions—is recommended [2,78,152].

GCR BLOC 1Grade of Recommendation B (Level of Evidence 1)

Comments: there are studies both confirming the effectiveness of relaxation methods in the treatment of panic disorder and describing their limited capabilities. The use of biofeedback and virtual reality allows the patient to learn to regulate their state and monitor it [1,176,251].

• For patients with panic disorder in whom history-taking reveals an intrapersonal conflict, the use of individual and group personality-oriented (reconstructive) psychotherapy—20-30 sessions—is recommended to reduce anxiety and panic attack frequency, resolve intrapersonal contradictions underlying panic symptoms, and overcome restrictive behavior [2,78,257].

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

Comments: personality-oriented (reconstructive) psychotherapy can be classified as the Russian equivalent of the psychodynamic approach. Psychotherapy aims to restore the patient's disrupted system of relations through the study of their specific personality disorders, analysis and awareness of the features of the patient's relationship system formation, the pathogenic situation, and the neurotic conflict. The balanced use of therapeutic mechanisms (confrontation, emotionally corrective experience, and learning) makes it possible to modify the patient's disturbed relationships, taking into account three planes of expected changes (in the cognitive, emotional, and motivational-behavioral spheres). 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, improves significantly.

• For patients with panic disorder and insomnia, a comprehensive medical and psychological treatment method for patients with insomnia is recommended to normalize sleep [233].

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

Comments: According to studies, sleep disturbances occur in 80% of patients with panic disorder (PD), which is a risk factor for a more severe course of PD and the development of comorbid affective disorders [234, 235]. An open-label randomized prospective controlled parallel-group study with blinded rater assessment was conducted in accordance with the clinical approbation protocol "Comprehensive Medical and Psychological Method for Insomnia Treatment" (protocol index: 2020-37-3). The quantitative evaluation of the clinical approbation method's efficacy was based on seven indicators: improvement in subjective sleep characteristics; improvement in sleep quality; reduction in the insomnia severity index; reduction in daytime sleepiness; reduction in the consequences of sleep disturbances; reduction in anxiety severity; and improvement in the Clinical Global Impression scale. The target outcome was achieved across all parameters, ranging from 87% to 100%. Although no isolated sample of patients with PD was singled out, a significant reduction in anxiety and normalization of sleep allow this methodology to be used in patients with anxiety disorders who have sleep disturbances, including PD. The comprehensive medical and psychological insomnia treatment program includes 10 individual cognitive behavioral therapy sessions (2 times a week, duration — 60 minutes) and 10 sessions of complex psychophysiological methods (3 times a week, duration — 60 minutes), including diaphragmatic breathing training (45 minutes) and light therapy (15 minutes). The total number of sessions is 20. The duration of the program is 5 weeks. During individual cognitive behavioral therapy, the patient learns the basic principles of sleep hygiene, techniques aimed at independently identifying and relieving neuropsychic tension, and the skills to identify and challenge dysfunctional beliefs regarding sleep, the causes of insomnia, and methods for its correction, which generally promotes the formation of a rational thinking system. The psychotherapy course, combined with light therapy and diaphragmatic breathing, aims to teach the patient self-analysis and self-regulation, enabling them to independently monitor and regulate their condition, recognize early manifestations of pathological states, independently prevent or stop them, and seek qualified medical help in a timely manner if necessary.

3.3 Other Treatment

• For patients with PD presenting with autonomic instability and autonomic regulation disorders, a 4-week course of biofeedback (BFB) therapy using EEG monitoring is recommended to train voluntary self-regulation skills for physiological responses [236, 237].

GCR CLOC 4Grade of Recommendations C (Level of Evidence 4)

Comments: As part of BFB therapy, a capnometry-controlled respiratory intervention is used; this is a 28-day home-based treatment that provides breath-by-breath feedback with information on breathing rate and exhaled carbon dioxide levels, aimed at normalizing breathing patterns and improving patients' ability to cope with symptoms of stress, anxiety, and panic. Medical instructors provide initial training followed by weekly monitoring during treatment. Remote data uploading and monitoring facilitate personalized training and analysis of cumulative results. BFB promotes the activation of the parasympathetic nervous system, which has a beneficial effect in the treatment of PD. Slow-paced breathing (SPB) training with heart rate variability (HRV) and biofeedback (BF) is an empirically proven behavioral therapy for reducing stress and anxiety. There are data on the use of BFB therapy during pregnancy [238].

• For patients with PD, especially those with treatment-resistant forms, transcranial magnetic stimulation is recommended to reduce anxiety levels and the frequency of panic attacks [177, 178, 179, 180, 181, 239, 240, 241, 242, 243, 244, 245].

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

Comments: Several studies describe the effects of pulsed (cyclic) transcranial magnetic stimulation [177, 178, 179]. Currently, the reliable recommendation base is insufficient. However, in some cases, particularly in treatment-resistant forms of PD, adding this method to psychopharmacotherapy and psychotherapy is advisable [180, 181, 239].

4. Medical Rehabilitation and Sanatorium-Resort Treatment

• All patients with PD are recommended to undergo rehabilitation measures to shorten the duration of temporary disability, ensure early social reintegration, and improve quality of life [2, 78, 83].

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

• For all patients with PD, sociocentric and psychocentric supportive psychotherapeutic methods are recommended in order to shorten the period of temporary disability, achieve early social reintegration, and improve quality of life [77, 78].

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

• For all patients with PD, family, social-psychological, and occupational supportive psychotherapy and/or psychocorrection are recommended as special types of rehabilitation to increase the quality and effectiveness of treatment [2, 78].

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

• For all patients with PD, supportive psychotherapy—which can be carried out on an outpatient basis as individual or group psychotherapy—is recommended as one of the important forms of rehabilitation measures to increase the quality and effectiveness of treatment [2, 78, 83, 136].

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

• All patients with PD are recommended to be monitored and managed by a psychotherapist or psychiatrist for therapy adjustment, correct discontinuation, and psychotherapy delivery [2, 78, 86].

RG CLE 5Recommendation Grade C (Level of Evidence 5).

• All patients with PD are recommended to undergo dispensary observation by a psychiatrist in cases of suicide risk, severe disease course, comorbid mental pathology, or treatment resistance, for the purpose of dynamic status assessment, determination of indications for outpatient treatment correction, and timely inpatient hospitalization [2, 78, 86].

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

• All patients with PD are recommended to perform an early set of aerobic exercises to enhance brain functional plasticity [246, 247, 248, 249, 250].

GOM BLOE 2Grade of Recommendation - B (Level of Evidence - 2).

Comments: The set of exercises significantly reduces the breathing rate, increases minute ventilation and the level of oxidative stress in the body. Aerobic exercise stimulates the production of endogenous cannabinoids (anandamide), opioids (beta-endorphin), and phenylethylamine, and increases levels of brain-derived neurotrophic factor (BDNF), thereby potentiating cognitive brain functions.

Physical exercises. Combine breathing with various movements that increase chest excursions. Breathing is combined with lateral torso bends and rotations, maximal utilization of accessory respiratory muscles, breathing against resistance, and relaxation exercises for the shoulder girdle, arms, and torso (swinging arm movements, forward bends, pronouncing buzzing, whistling, and hissing sounds, etc.). Sessions lasting 15–20 minutes are conducted 2–3 times a week for at least 4 weeks.

Respiratory gymnastics. Exhalation with resistance. After a sufficiently deep inhalation, exhale as slowly as possible through a tube into water. The exercise is repeated 4–5 times a day for 10–15 minutes.

Diaphragmatic breathing. Lying on their back, the patient takes a powerful, prolonged, deep exhalation over 3 seconds involving the abdominal muscles (the abdomen should be strongly pulled in), followed by a 1-second diaphragmatic inhalation with maximal protrusion of the abdomen. Then, by quickly contracting the abdominal muscles, give a muffled cough. The exercise is performed lying down, sitting, standing, or during running or walking.

Walking. Must be regular, and the load adequate to the patient's condition. For patients with high physical exertion tolerance, walking is alternated with metered slow running at a slow pace without accelerations or sudden jerks. Such running should not cause shortness of breath or cardialgia. The heart rate should not exceed 80% of the individual submaximal threshold load.

Terrain cure (terrenkur). Alternation of walking on flat terrain and ascents from 3 to 15 degrees. The load is determined by the heart rate, which should be 50–60% of the submaximal heart rate for the given age or individualized for the patient. The walking pace should be slow (60–80 steps per min) or medium (80–100 steps per min).

5. Prevention and Dispensary Observation

There is no specific prophylaxis to prevent the recurrence of panic attacks. The prevention of PD involves the implementation of healthy lifestyle principles, measures aimed at maintaining mental health among the population, and the restriction of alcohol and psychoactive substance use. It also includes informing the public about the signs of PD for early detection and timely medical care-seeking.

• All patients with panic disorder are recommended to adhere to a healthy lifestyle and implement measures aimed at maintaining public mental health in order to prevent anxiety disorders [1,2,3,134,139,182].

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

Comments: there are studies confirming that physical activity can reduce the risk of panic disorder and contribute to more effective coping with anxiety [182].

6. Organization of Medical Care

Indications for hospital admission to a medical organization:

1) high frequency of panic attacks requiring pharmacotherapy adjustment in an inpatient setting;

2) severe anxiety requiring pharmacotherapy adjustment in an inpatient setting;

3) presence of comorbid mental disorders requiring drug therapy adjustment in an inpatient setting;

4) presence of comorbid somatic disorders requiring drug therapy adjustment in an inpatient setting;

5) severe phobic states with restrictive behavior, persistent agoraphobia significantly impairing the patient's mobility;

6) poor tolerability of drug therapy.

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 panic attacks;

4) reduction in anxiety levels;

5) stabilization of the mental state;

6) stabilization of the somatic state;

7) relief of phobic states with overcoming of restrictive behavior.

7. Additional Information

7.1 Factors (predictors) contributing to a protracted course

Main predictors of a protracted course of panic disorder [3;17;18]:

Criteria for Evaluating the Quality of Medical Care

Quality assessment criteria for primary health care delivered to adults with panic disorder (ICD-10 code F41.0)

Quality assessment criteria for specialized medical care delivered to adults with panic disorder (ICD-10 code F41.0)

References

Appendix A1. Working Group Composition

1. Vasilieva Anna Vladimirovna - Doctor of Medical Sciences, Associate Professor, Chief Researcher at the Department of Borderline Mental Disorders and Psychotherapy, V.M. Bekhterev National Medical Research Center for Psychiatry and Neurology of the Russian Ministry of Health, Member of the Russian Psychotherapeutic Association, Member of the Russian Society of Psychiatrists.

2. Zinchenko Yury Petrovich - 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, Academician of the RAE, President of the Russian Psychological Society.

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

4. Kalashnikova Rezeda Nailievna - medical psychologist at the Leningrad Regional Psychoneurological Dispensary, Chief freelance specialist in medical psychology of Leningrad Oblast, Member of the Saint Petersburg Psychological Society.

5. Karavaeva Tatyana Arturovna - Doctor of Medical Sciences, Associate Professor, Head of the Federal Consultative and Methodological Center for Psychotherapy of the Russian Ministry of Health, Head and Chief Researcher at the Department of Borderline Mental Disorders and Psychotherapy of 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 of Saint Petersburg State University, Professor at the Department of General and Applied Psychology with Courses in Biomedical Disciplines and Pedagogy of the Saint Petersburg State Pediatric Medical University of the Russian Ministry of Health, Leading Researcher at the Scientific Department of Innovative Methods of Therapeutic Oncology and Rehabilitation of the N.N. Petrov National Medical Research Center of Oncology of the Russian Ministry of Health, Vice President of the Russian Psychotherapeutic Association (RPA), Member of the Russian Society of Psychiatrists, Head of the Working Group on the Preparation of Clinical Guidelines for "Panic Disorder"

6. Mizinova Elena Borisovna - Candidate of Psychological Sciences, Senior Researcher at the Department of Borderline Mental Disorders and Psychotherapy of the V.M. Bekhterev National Medical Research Center for Psychiatry and Neurology of the Russian Ministry of Health, Member of the Russian Psychotherapeutic Association, Member of the Russian Society of Psychiatrists.

7. Mosolov Sergey Nikolaevich - Doctor of Medical Sciences, Professor, Honored Scientist of the Russian Federation, Head of the Department of Therapy of Mental Diseases at the Moscow Research Institute of Psychiatry - Branch of the V.P. Serbsky National Medical Research Center for Psychiatry and Narcology of the Russian Ministry of Health, Head of the Department of Psychiatry at the Russian Medical Academy of Continuous Professional Education of the Ministry of Health of the Russian Federation, Member of the Executive Committee of the Russian Society of Psychiatrists.

8. Ponomarenko Gennady Nikolaevich - Corresponding Member of the RAS, Honored Scientist of the Russian Federation, Professor, Doctor of Medical Sciences, General Director of the G.A. Albrecht Federal Scientific and Educational Center of Medical-Social Expertise and Rehabilitation of the Ministry of Labor of the Russian Federation, 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.

9. Potanin Sergey Sergeevich - Candidate of Medical Sciences, Junior Researcher at the Laboratory of Psychopharmacology of the Mental Health Research Center of the RAS, Member of the Russian Society of Psychiatrists.

10. Radionov Dmitry Sergeevich - Junior Researcher at the Department of Borderline Mental Disorders and Psychotherapy of 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.

11. Khasanova Aiperi Kylychbekovna - Assistant at the Department of Psychiatry of RMANPO, Member of the Russian Society of Psychiatrists.

Conflict of interests: none

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience of 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. Scale for assessing levels of evidence (LE) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, rehabilitation interventions)

Table 3. Scale for assessing grades of recommendation (GR) for prevention, diagnosis, treatment and rehabilitation methods (preventive, diagnostic, therapeutic, 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 data from the perspective of evidence-based medicine regarding 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 Russian Ministry of Health No. 459n dated 04.07.2022 "On Approval of the Standard of Medical Care for Adults with Panic Disorder (Diagnosis and Treatment)"

2. Recommended drug doses for the treatment of PD

Table 1.

Appendix B. Physician Action Algorithms

Appendix B1. Algorithm for managing patients with PD

Appendix B4. Algorithm for the prevention and management of patients with antidepressant discontinuation syndrome

Note. AD - antidepressant, SSRI - selective serotonin reuptake inhibitor, SNRI - selective serotonin and norepinephrine reuptake inhibitor, ADDS - antidepressant discontinuation syndrome.

In the event of a decision to discontinue long-term antidepressant therapy, a gradual reduction of the AD dose is most preferred; in cases of high risk for antidepressant discontinuation syndrome (ADDS), the slowest possible dose reduction is desirable. However, there are no uniform recommendations regarding the duration of the gradual AD taper period or the minimum dose to which the medication should be reduced prior to cessation. If ADDS cannot be avoided and is mild in severity, pharmacotherapy is not indicated, and it is sufficient to inform the patient about the temporary nature of the symptoms. For moderate severity of ADDS, symptomatic therapy is required. In cases of severe symptoms upon discontinuation of an AD or a significant reduction in its dose, the following options may be utilized, which are equivalent to each other, i.e., have no specific order of application: 1) resume the AD at the minimum effective dose or at the dose where no withdrawal symptoms occurred, followed by discontinuation through a more fractional and slower titration; 2) when discontinuing an AD from the SSRI or SNRI group, one can switch to fluoxetine, stopping the original AD after several weeks of fluoxetine treatment and gradually tapering the latter thereafter; when discontinuing an AD from other groups, one can switch to a pharmacologically similar AD with a longer half-life and subsequently gradually taper both ADs as in the case of switching to fluoxetine.

Appendix C. Patient Information

What is panic disorder?

Panic disorder is a disorder of the nervous system whose main manifestation is anxiety attacks that occur for insignificant reasons or in the absence of any reasons, unrelated to real danger.

What are the main symptoms of panic disorders?

A suddenly arising unreasonable feeling of anxiety (panic attack), breathing difficulties, dizziness, fear of death or impending catastrophe, chest or abdominal pain, feeling of a "lump in the throat", etc.

Diagnosis of panic disorder.

Typically, the diagnosis of panic disorder is established after ruling out all conditions that may present with similar symptoms. Panic attacks are diagnosed and treated by a psychotherapist or psychiatrist.

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

Treatment of panic disorder.

Treatment of panic disorder includes psychotherapy and the prescription of medications that reduce anxiety (anxiolytics).

Psychotherapy incorporates various techniques that help patients with anxiety disorders accurately assess situations and achieve relaxation during an anxiety attack. 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 stressors.

Pharmacotherapy for panic disorder involves the use of various agents affecting anxiety. Medications that reduce the feeling of anxiety are called anxiolytics (sedatives). Medical treatment — prescription, therapy adjustment, and discontinuation of drugs — is carried out exclusively by a specialist physician.

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

Appendix G1. Questionnaire for identifying signs of autonomic changes

Russian title: Questionnaire for Identifying Signs of Autonomic Changes — Wayne Scale (Vein A.M. et al., 1998).

Original title: Questionnaire for Identifying Signs of Autonomic Changes — Wayne Scale.

Source (official developer website, validation publication):

A.M. Vein (Ed.). Autonomic Disorders: Clinic, Diagnosis, Treatment. Moscow: MIA, 2003.

Type (underline):

- assessment scale

- score

- questionnaire

- other (specify):

Purpose: The questionnaire is intended for screening studies to identify autonomic dysfunction syndrome (ADS).

The Wayne Scale is a self-report questionnaire filled out by the subject/patient. While completing the test, the respondent underlines the corresponding "Yes" or "No" answer across 11 questions describing the main symptoms of autonomic changes.

Content (template):

Key (interpretation):

To quantify the identified signs, an expert assessment of autonomic symptoms was performed by scoring each sign according to its specific weight among various symptoms of VSD (vegetovascular dystonia syndrome). Based on this, a corresponding score from 1 to 10 was assigned to each symptom in the case of a positive response to the respective question.

The total score obtained from evaluating the signs using the questionnaire , in healthy individuals should not exceed 15, while exceeding this value indicates the presence of VSD.

Appendix G2. Panic Disorder Severity Scale

Russian title: Panic Disorder Severity Scale (adapted by Fedotov I.A., 2022).

Original title: Panic Disorder Severity Scale - (PDSS) (Shear M., Brown T. et al., 1997).

Source (official developer website, validation publication):

Shear M.K., Brown T.A., Barlow D.H., Money R., Sholomskas D.E., Woods S.W., Gorman J.M., Papp L.A. Multicenter collaborative Panic Disorder Severity Scale. American Journal of Psychiatry 1997;154:1571-1575. Methodology adaptation: Fedotov I.A. Panic Disorder Severity Scale // Clinical Psychometrics - Textbook (ed. by Soldatkin V.A.). - M.: Knorus, 2022. - 664 p.

Type (underline):

- rating scale

- score

- questionnaire

- other (specify):

Purpose: The Panic Disorder Severity Scale (PDSS) is used as a screening tool for the initial identification of panic disorder symptoms and for assessing the overall symptom severity of already diagnosed panic disorder.

The Panic Disorder Severity Scale (PDSS) is used in 2 versions: one is designed to be completed by the subject themselves, i.e., as a self-report scale, and the other is designed to be completed by a specialist (general practitioner, family doctor, psychiatrist, etc.), serving as a clinician-rated scale.

Assessment using the PDSS self-report scale takes 5–7 minutes, during which the subject assesses their condition—specifically, panic attacks over the past 7 days—by independently answering 7 questions presented in the questionnaire, choosing one of 5 response options for each question, carrying a weight from 0 to 4 points.

Completion of the PDSS clinician-rated scale is performed by a specialist during a semi-structured interview, in which the physician collects anamnestic data and observes behavior and other non-verbal manifestations of the investigated psychopathological phenomena.

Content (template):

Instructions for the subject: Please answer the following questions based on the past 7 days. If the situations described in the questions did not occur during the past week or occurred less frequently than usual, answer as if they had occurred and as if everything were as normal.

For the purposes of this questionnaire, a panic attack is defined as a sudden surge of fear or discomfort, lasting from 10 to 60 minutes (rarely a couple of hours), accompanied by 4 or more of the following symptoms:

• Rapid or pounding heartbeat

• Sweating

• Nausea

• Chest pain or discomfort

• Dizziness

• Fear of going crazy or losing control

• Dyspnea

• Numbness or tingling

• Feeling of choking

• Fear of death

• Chills or hot flashes

• Feelings of unreality

If fewer than 4 symptoms are present, it is defined as a limited-symptom (incomplete) panic attack.

Questions:

1. How many full-symptom or limited-symptom panic attacks have you had over the past 7 days?

0. None.

1. No full-symptom panic attacks and no more than 1 limited-symptom attack per day.

2. 1–2 full-symptom panic attacks per day and/or many limited-symptom attacks per day.

3. More than 2 full-symptom attacks over the week, but no more than 1 attack per day on average.

4. Full-symptom panic attacks occur more than 1 time per day on most days of the week.

2. If you have had panic attacks over the past 7 days, how severe was the discomfort (anxiety, distress) they caused you at the time of their occurrence? (If there were multiple attacks, provide an average estimate. If you only had limited-symptom attacks, answer regarding them):

0. They did not bother me at all or did not occur last week.

1. Mild discomfort (not very intense).

2. Moderate discomfort (intense, but manageable).

3. Severe discomfort (very intense).

4. Extreme discomfort (extremely intense distress during all panic attacks).

3. How often and how intensely over the past 7 days have you worried about when the next panic attack will happen, and about the fears that arise during a panic attack? (For example, that panic attacks indicate you have a mental or physical illness, or that they might cause public disapproval directed at you):

0. Not at all.

1. Episodic or only mild worry.

2. Frequent or moderate severity.

3. Very frequent or intense.

4. Almost constant or "paralyzing" in intensity.

4. During the past 7 days, were there any situations or places (e.g., public transport, cinemas, bridges, tunnels, hypermarkets, being alone, etc.) that you avoided or felt fear in at that time (internal discomfort, a desire not to enter those situations or to leave them immediately) due to the fear that a panic attack might start? Were there any other situations that you avoided or were afraid of during the past week? If so, please rate the level of fear and anticipation last week:

0. No fear or avoidance.

1. Mild: episodic fear and avoidance occurred, which I was able to manage. This changed my usual lifestyle very little last week.

2. Moderate: noticeable but controllable fear and/or avoidance. I avoided certain situations, but in the company of a familiar person I could feel comfortable in them. My usual lifestyle was altered as a result, but my overall functioning was not impaired.

3. Severe: extensive avoidance. It required a significant change to my usual lifestyle to avoid frightening situations.

4. Extreme: pervasive disabling fear and/or avoidance. It required a major change to my usual lifestyle, and important tasks were left undone.

5. During the past 7 days, were there any activities (e.g., physical exercise, sexual relations, taking a hot shower or bath, drinking coffee, watching horror movies, etc.) that you avoided or felt afraid of because they caused physical sensations similar to those of a panic attack, or you were afraid they might trigger the onset of a panic attack?

0. No fear or avoidance.

1. Mild: episodic fear and avoidance occurred, but I was usually able to manage it. This required a slight change to my usual lifestyle.

2. Moderate: noticeable but controllable fear and/or avoidance. The change in routine was noticeable but limited and did not cause impairment in overall functioning.

3. Severe: extensive avoidance. It required a significant change to my usual lifestyle and functioning.

4. Extreme: pervasive disabling avoidance. It required a major change to my usual lifestyle, and important tasks were left undone.

6. During the past 7 days, how often did panic disorder symptoms interfere with your work performance and ability to do household chores? (If your workload at work or home was less than usual last week, answer how you think it would have combined if your workload had been normal):

0. No impact on work performance and ability to do household chores.

1. There was a mild impact on work and chores, but I was able to complete almost everything I would have done if the symptoms had not been present.

2. There was a significant impact on work and chores, but I was able to manage and complete all necessary tasks.

3. There were substantial impairments in work or domestic spheres; due to these problems, I was unable to complete many important things.

4. There were extreme, incapacitating impairments due to which I was unable to fulfill work and household duties.

7. During the past 7 days, how often did full-symptom or limited-symptom panic attacks, as well as worry about the possibility of their occurrence, interfere with your social life? (If you did not have the opportunity to spend much time in public last week, answer as if you had those opportunities as usual):

0. No impact.

1. There was a mild effect on social activity, but I was able to do almost everything just as if these problems did not exist.

2. There was a significant effect on social activity, but I was able to do the most important things.

3. There was a marked effect on social activity; I was unable to fulfill many plans due to these problems.

4. There were extreme, disabling impairments that made it difficult to do anything social.

Key (interpretation):

PDSS consists of 7 items, each scored on a 5-point scale ranging from 0 to 4 points. The questionnaire items assess the following symptoms of panic disorder:

1. frequency of panic attacks,

2. distress during a panic attack,

3. panic-focused anticipatory anxiety,

4. phobic avoidance of situations,

5. phobic avoidance of physical sensations,

6. impairment in work performance,

7. impairment in social functioning.

The overall assessment is based on the total score, which is calculated by summing the scores across all 7 items. The total score ranges from 0 to 28.

A score of 9 points or higher indicates the need for a formal diagnostic evaluation.

Assessment of panic disorder symptom severity:

Appendix G3. Screening Questionnaire for Panic Attacks

Russian title: Panic Screening Questions (Anxiety and Panic Questions).

Original title: Panic Screening Questions - (PHQ) (Spitzer R.L., Kroenke K., Williams J.B. et al., 1999)

Source (official developer website, validation publication):

Spitzer R.L., Kroenke K., Williams J.B. et al. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study // Jama. - 1999. - Vol. 282. - No. 18. - P. 1737-1744.

Type (underline):

- rating scale

- score

- questionnaire

- other (specify):

Purpose: Conducting a screening survey to detect the presence of panic attacks.

The PHQ questionnaire is a self-report scale and is completed by the subject/patient.

Content (template):

1. Question regarding the presence of anxiety attacks (response options "Yes" or "No")

a) have you experienced attacks of sudden anxiety, fear, or terror over the past 4 months? (if "Yes", continue answering the questions) _____

b) have you ever had similar attacks in the past? __________________

c) do some of these attacks occur unexpectedly, unrelated to a specific situation where you would feel anxious or uncomfortable? _________

d) do you have a fear of an attack or its consequences? _______________________

2. During your last attack, did you experience (answer "Yes", "No"):

a) shallow, rapid breathing

b) palpitations, pounding heart, skipped beats, or a feeling that the heart stopped

c) pain or discomfort in the left side of the chest

d) sweating

e) feeling of air hunger, shortness of breath

f) waves of heat or cold

g) nausea, stomach discomfort, diarrhea, or urges to defecate

h) dizziness, instability, brain fog, or pre-syncope

i) tingling or numbness in the body or extremities

j) trembling in the body or extremities, muscle twitching or tightness in the body (extremities)

k) fear of dying or of irreversible consequences of the attack?

Key (interpretation):

If the patient answers "Yes" to items 1 a–d and "Yes" to any 4 items from 2 a–k, panic disorder (PD) may be suspected.

Notes: Sensitivity of the method is 81%, specificity is 99%. This tool is for screening purposes and requires further clinical evaluation to establish a diagnosis of PD.

Appendix G4. Hamilton Anxiety Rating Scale

Russian title: 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

- score

- 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 doctors, psychiatrists, etc. The scale is completed during a semi-structured interview, during which the specialist also collects anamnestic data and observes the behavior and other non-verbal manifestations of the studied psychopathological phenomena. The scale should not be handed to the patient, nor should direct questions from it be read aloud to them.

HARS consists of 14 items, each scored on a Likert scale. 13 items relate to manifestations of anxiety in everyday life. The 14th relates to the manifestation of anxiety during the examination. Response options are standardized: each item can contribute an equal number of points to the scale value, and there is no need to spell out separate response options for each item, which greatly simplifies the understanding of the scale and the scoring procedure.

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, crying easily, trembling, feelings of restlessness, inability to relax).

0. Absent.

1. Mild.

2. Moderate.

3. Severe.

4. Very severe.

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

0. Absent.

1. Mild.

2. Moderate.

3. Severe.

4. Very severe.

4. Insomnia (difficulty falling asleep, broken sleep, unsatisfying sleep with fatigue and weakness upon awakening, nightmares).

0. Absent.

1. Mild.

2. Moderate.

3. Severe.

4. Very severe.

5. Intellectual (cognitive) impairment (difficulty concentrating, poor memory).

0. Absent.

1. Mild.

2. Moderate.

3. Severe.

4. Very severe.

6. Depressive mood (loss of usual interests, loss of pleasure from hobbies, depressed mood, early awakening, diurnal fluctuations in mood).

0. Absent.

1. Mild.

2. Moderate.

3. Severe.

4. Very severe.

7. Somatic symptoms (aches and pains, muscle twitches, tension, myoclonic jerks, teeth grinding, strained voice, increased muscle 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, tingling sensations).

0. Absent.

1. Mild.

2. Moderate.

3. Severe.

4. Very severe.

9. Cardiovascular symptoms (tachycardia, palpitations, chest pain, vascular pulsation, feeling faint, frequent sighs, dyspnea).

0. Absent.

1. Mild.

2. Moderate.

3. Severe.

4. Very severe.

10. Respiratory symptoms (feeling of chest pressure or constriction, choking sensation, frequent sighs, dyspnea).

0. Absent.

1. Mild.

2. Moderate.

3. Severe.

4. Very severe.

11. Gastrointestinal symptoms (difficulty swallowing, flatulence, abdominal pain, heartburn, feeling of stomach fullness, nausea, vomiting, abdominal rumbling, diarrhea, weight loss, constipation).

0. Absent.

1. Mild.

2. Moderate.

3. Severe.

4. Very severe.

12. Genitourinary symptoms (frequency of urination, urgent need to urinate, amenorrhea, menorrhagia, frigidity, premature ejaculation, loss of libido, impotence).

0. Absent.

1. Mild.

2. Moderate.

3. Severe.

4. Very severe.

13. Autonomic symptoms (dry mouth, flushing, pallor, excessive sweating, tension headaches).

0. Absent.

1. Mild.

2. Moderate.

3. Severe.

4. Very severe.

14. Examination behavior (fidgeting, restless gesturing or pacing, hand tremor, frowning, tense facial expression, sighing or hyperventilation, 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 for 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 — worries, anticipation of the worst, fearful apprehension, irritability.

2. Tension — feelings of tension, startle response, tendency to cry easily, trembling, restlessness, inability to relax.

3. Fears — fear of the dark, strangers, animals, traffic, crowds, fear of being left alone.

4. Insomnia — difficulty falling out to sleep, broken sleep, unrefreshing sleep with feelings of fatigue and weakness upon waking, nightmares.

5. Intellectual impairment — difficulty concentrating, memory impairment.

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

7. Somatic symptoms (muscular) — aches and pains, muscle twitches, tension, myoclonic jerks, teeth grinding, strained voice, increased muscle tone.

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

9. Cardiovascular symptoms — tachycardia, palpitations, chest pain, vascular pulsation, feeling faint, frequent sighs, dyspnea.

10. Respiratory symptoms — feeling of chest pressure or constriction, choking sensation, frequent sighs, dyspnea.

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

12. Genitourinary symptoms — frequency of urination, urgent need to urinate, amenorrhea, menorrhagia, frigidity, premature ejaculation, loss of libido, impotence.

13. Autonomic symptoms — dry mouth, flushing, pallor, excessive sweating, tension headaches.

14. Examination behavior — fidgeting, restless gesturing or pacing, hand tremor, frowning, tense facial expression, sighing or hyperventilation, facial pallor, frequent swallowing, etc.

Appendix G5. Symptom Checklist-90-Revised

Russian title: Symptom Checklist-90-Revised.

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. Workshop on the Psychology of Post-Traumatic Stress. - St. Petersburg: Piter, 2001. - 272 p.

Type (underline):

- assessment scale

- score

- questionnaire

- other (specify):

Purpose: The SCL-90-R questionnaire is a self-report scale designed to determine the subject's current psychological symptomatic status. The SCL-90-R is a testing and screening method designed to assess psychological symptom patterns in psychiatric patients and healthy individuals.

The SCL-90-R questionnaire is completed by the subject/patient and consists of 90 items, each rated on a 5-point distress 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 the 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 leading dimensions and are grouped separately as additional developing 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:

Data processing:

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

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

3. PSI (Positive Symptom Index).

Calculate the number of items rated from 1 to 4.

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

Summary normative 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. If an organic basis for the complaints is ruled out, various somatoform disorders and anxiety equivalents are recorded.

2. Obsessive-Compulsive. The core of this scale is the eponymous clinical syndrome. It includes items indicating the repetitiveness 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 interactions. The scale includes items reflecting self-deprecation, self-consciousness, and marked discomfort during interpersonal interactions. It reflects a tendency toward reflection and lowered self-esteem.

4. Depression. Items pertaining to the depression scale reflect a wide range of circumstances accompanying the clinical depressive syndrome. Complaints regarding 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, worthlessness, and other somatic and cognitive characteristics of depression.

5. Anxiety. This scale includes a group of symptoms and reactions typically associated clinically with overt (manifest) anxiety, reflecting a sense of oppressive, motiveless 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 related to travel, open spaces, public places, transportation, and social phobic reactions.

8. Paranoid Ideation. When creating this scale, L.R. Derogatis et al. adhered to the view that paranoid phenomena are best understood when perceived as a mode of thinking. Features of paranoid thinking of primary importance, within the constraints imposed by the questionnaire, were included in the scale. These primarily include projective thinking, hostility, suspiciousness, and ideas of reference.

9. Psychoticism. The basis of this scale includes 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 G6. Integrative Anxiety Test

Title in Russian: Integrative Anxiety Test (IAT) (Biziuk A.P., Vasserman L.I., Iovlev B.V., 1997).

Original title: Integrative Anxiety Test (IAT) (Biziuk A.P., Vasserman L.I., Iovlev B.V., 1997).

Source (official developer website, validation publication):

Developed in the Laboratory of Clinical Psychology at the V.M. Bekhterev Institute (Biziuk A.P., Vasserman L.I., Iovlev B.V., 1997). Biziuk A.P. Application of the Integrative Anxiety Test (IAT) // Methodological recommendations / A.P. Biziuk, L.I. Vasserman, B.V. Iovlev. - St. Petersburg: V.M. Bekhterev St. Petersburg Psychoneurological Research Institute Publishing House, 2003. - 23 p.

Type (underline):

- assessment scale

- score

- questionnaire

- other (specify):

Purpose: The Integrative Anxiety Test (IAT) methodology is a medical (medical-psychological) technology, serving as an original express psycho-diagnostic tool for the differentiated assessment and qualitative evaluation across 5 factors (subscales) of anxiety as a non-specific affective behavioral regulator of personality (complex in genesis) and anxiety as a personality-typological characteristic. The analysis of the adaptogenic and pathogenic role of the "anxiety-trait/state tandem" allows for refining therapy mechanisms and evaluating the effectiveness of treatment for mental maladaptation of various origins.

To assess the level of significance for respondents of 15 statements across the anxiety self-assessment scales—situational (AST-S) and trait (AST-T)—a traditional 4-point grading system of subjective personal rating was used: 0 - absence of the trait, two others 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 IAT scales is 45.

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

Full Name __________________________________________________________________

Age ________________________________________________________________

Date of examination _______________________________________________________

Location of examination _____________________________________________________

Below are several statements concerning your emotional state. For each one, 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 ________________________________________________________________

Date of examination _______________________________________________________

Location of examination _____________________________________________________

Below are several statements concerning your emotional state. For each of them, you need to decide how pronounced this state is RIGHT NOW, AT THIS VERY MOMENT, TODAY. Depending on this, place a «+» sign in one of the four columns.

Key:

Conversion table to stanines for the overall trait anxiety score (T-ST) and overall state anxiety score (S-ST).

Scoring table for the auxiliary subscales of trait anxiety (T-ST) and state anxiety (S-ST).

Conversion to stanines for the auxiliary subscale scores of trait anxiety (T-ST) and state anxiety (S-ST) in adults and young men.

Conversion to stanines for the auxiliary subscale scores of trait anxiety (T-ST) and state anxiety (S-ST) in young women.

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 «Social Reaction of Defense» (SRZ) subscale is associated with the main manifestations of anxiety in social contacts; high scores on this subscale indicate the subject's attempt to view the social environment as the primary source of anxiety tension and lack of self-confidence.

Appendix G7. C.D. Spielberger and Yu.L. Khanin Anxiety Assessment Scale

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

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

Source (official developer website, validation publication):

Spielberger C.D., Gorsuch R.L., Lushene. R.E. Manual for the State-Trait Anxiety Inventory.// Palo Alto, C.A: 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 reactive and trait anxiety scale of C.D. Spielberger. - Leningrad. - 1976. - 18 p.

Type (underline):

- assessment scale

- score

- questionnaire

- other (specify):

Purpose: The C.D. Spielberger and Yu.L. Khanin Anxiety Assessment Scale is a self-assessment scale for measuring the level of anxiety at the given moment (reactive anxiety as a state) and trait anxiety (as a stable personality characteristic). It is used in clinical practice to determine the severity of anxiety symptoms, assess state dynamics, etc. Comparison of results on both subscales allows for evaluating the individual significance of a stressful situation for the subject.

Content (template):

State Anxiety Scale.

Instructions. 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 moment. Do not dwell on the questions for too long, as there are no right or wrong answers.

Personal Anxiety Scale.

Instructions. Carefully read each of the statements below and cross out the number in the corresponding column on the right, depending on how you usually feel. Do not spend too much time thinking about the questions, as there are no right or wrong answers.

Key:

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:

TA = Erp - Ero + 50, where:

TA is the reactive anxiety score;

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

Ero 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:

LA = Elp - Elo + 35, where:

LA is the personal anxiety score;

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

Elo 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 temporal stability and intensity depending on the magnitude of the stressor's impact. Thus, the value of the final score on this subscale makes it possible to assess not only the subject's current anxiety level, but also to determine whether they are under the influence of a stressful situation and what the intensity of this impact is on them.

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 G8. Beck Anxiety Inventory

Russian title: Beck Anxiety Inventory.

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

Source (official developers' website, validation publication): Beck AT, Steer RA (1993). Beck Anxiety Inventory Manual. San Antonio: Harcourt Brace and Company.

Type (underline):

- assessment scale

- score

- questionnaire

- other (specify):

Purpose: A clinical testing tool designed for anxiety screening and assessment of its severity.

The Beck Anxiety Inventory (BAI) is a self-report scale designed for the preliminary assessment of the severity of anxiety disorders in a wide range of individuals: adolescents from 14 years of age, adults and the elderly, clinical populations, and for screening studies.

The questionnaire consists of 21 items. Each item includes one of the typical symptoms of anxiety, somatic or psychological. Each item must be rated by the respondent (subject/patient) from 0 (symptom did not bother me) to 3 (symptom bothered me very much).

Content (template):

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

Key (interpretation):

Scoring is performed by simply summing the scores 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 severity. Scores from 36 to 63 indicate very high anxiety.

Appendix G9. Sheehan Anxiety Scale

Russian title: Sheehan Patient-Rated Anxiety Scale.

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

Source (official developer website, validation publication):

Sheehan D.V., Sheehan Kr. // Int. J. Psycriat. Med, - 1983. - N 12. - P. 243-266.

Type (underline):

- assessment scale

- score

- questionnaire

- other (specify):

Purpose: The Sheehan Patient-Rated Anxiety Scale is intended for screening diagnostics 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 the symptoms listed below have bothered you over the past week. Indicate 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 Zung Self-Rating Anxiety Scale

for panic disorder and agoraphobia (in neurotic disorders) range from 37 to 77 points.

Appendix G10. Minnesota Multiphasic Personality Inventory (MMPI)

Russian title: Standardized Clinical Personality Questionnaire, adapted by I.N. Gilyasheva, L.N. Sobchik, and T.L. Fedorova, full version of the MMPI - (SKLO).

Original title: Minnesota Multiphasic Personality Inventory - (MMPI) (Hathaway S.R. & McKinley J.C., 1948, 1954).

Source (official developer website, validation publication):

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. Adaptation of the method by L.N. Sobchik, Serbsky National Medical Research Center for Psychiatry and Narcology, 1971. Sobchik L.N., Standardized Multifactorial Personality Investigation Method SMIL (MMPI): Practical Guide. — Moscow: Rech, 2007. — 224 p.

Type (underline):

- assessment scale

- score

- questionnaire

- other (specify):

Purpose: The MMPI questionnaire is intended for assessing individual personality traits, emotional state, and adaptation mechanisms in adults.

The questionnaire text includes 566 statements concerning well-being, habits, behavior, prevailing experiences and mood, attitudes towards various life phenomena, interpersonal relationships, and orientation of interests. As a result of processing, the investigator obtains scores on 3 control scales (intended to determine the subjects' attitude toward testing) and 10 basic scales, which together represent the subject's "personality profile".

Appendix G11. Ammon's Ego-Structure Test

Russian title: Ammon's Ego-Structure Test.

Original title: Ich-Struktur-Test nach G.Ammon - (ISTA) (Gunter Ammon et al., 1997).

Source (official developer website, validation publication):

Ammon G. Das Verstandniseines Entwicklungsdefizitsvon Ich-Strukturenin Personlichkeitundumgebender Gruppeals Grundlagefiir Wisscnschaftund Praxiseiner Dynamischen Psychiatrie. — Dynamische Psychiatrie, 1978, Jg. 11, s. 120-140. Adapted and re-standardized at the V.M. Bekhterev Saint Petersburg Research Institute. Ammon's Ego-Structure Test. A questionnaire for assessing central personality functions at the structural level: A guide for psychologists and physicians / author-comp. Yu.Ya. Tupitsyn, V.V. Bocharov, T.V. Alkhazova et al. - SPb.: V.M. Bekhterev Psychoneurological Research Institute, 1998 - 70 p.

Type (underline):

- assessment scale

- score

- questionnaire

- other (specify)

Purpose: is a questionnaire developed by the author and his associates. It registers 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 G12. Locus of Control Questionnaire

Russian title: Methodology for Determining the Level of Subjective Control (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. Adaptation: Bazhin E.F., Golynkina E.A., Etkind A.M. A method for studying the level of subjective control // Psychological Journal. 1984. Vol. 5, no. 3, pp. 152-162.

Type (underline):

- assessment scale

- score

- 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 person'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 strategies a person chooses for their behavior can 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 illness and health.

Appendix G13. Personality Beliefs Questionnaire

Russian title: Personal Beliefs Questionnaire.

Original title: Personal Beliefs Test (Kassinove, Howard, 1988).

Source (official developer website, validation publication): Kassinove H., Berger A. Survey of personal beliefs//Hofstra University: Personal communication - 1988. - P. 100 - 113. Adaptation of the methodology: Nazyrov R.K., Logacheva S.V., Remeslo M.B., Kholyavko V.V., Pavlovsky I.O. Typology of psychotherapeutic targets and its use to improve the quality of individual psychotherapeutic programs in the treatment of patients with neurotic disorders // Methodological recommendations. - SPb.: V.M. Bekhterev NIPNI Publishing House. - 2011.

Type (underline):

- assessment scale

- score

- questionnaire

- other (specify):

Purpose: The questionnaire was originally developed at Hofstra University (USA) by Howard Kassinove and Andrew Berger (1981); it is designed to diagnose rational thinking and identify irrational beliefs (attitudes) characteristic of patients with neurotic disorders. The theoretical basis for creating the methodology was A. Ellis's rational-emotive psychotherapy. Later, the authors made some changes to the questionnaire's content, the appropriateness of which was confirmed by factor analysis. The main purpose of the questionnaire is to study respondents' rational and irrational ideas (attitudes).

The questionnaire includes 5 scales:

1. "Demandingness towards oneself".

2. "Self-evaluation".

3. "Catastrophizing".

4. "Demandingness towards others".

5. "Low frustration tolerance".

6. "General (integral) indicator of rational thinking".

Appendix G14. Life Style Index (LSI)

Russian title: Life Style Index - (LSI).

Original title: Life style index - (LSI) (Kellerman-Plutchik, 1979).

Source (official developer website, validation publication):

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. Adaptation of the methodology: Wasserman L.I. 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. Psychological diagnostics of the life style index: a methodological guide for physicians and psychologists. - SPb.: V.M. Bekhterev NIPNI, 1998. - 48 p.

Type (underline):

- assessment scale

- score

- questionnaire

- other (specify):

Purpose: a personality questionnaire designed to assess the severity of 8 main psychological defense mechanisms (8 scales obtained through factor analysis): denial, projection, regression, compensation, repression, displacement, intellectualization, and reaction formation. The questionnaire consists of 97 items and allows assessing 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 set of scaled scores reflects the individual structure of a person's psychological defense, and overall, the individual's defensive behavior style.

Appendix G15. Lazarus Stress Coping Strategies (SCS).

Russian title: Lazarus Stress Coping Strategies (SCS).

Original title: Ways of Coping Questionnaire - (WCQ) (Folkman S., Lazarus R., 1988).

Source (official developer website, validation publication):

Folkman S., Lazarus R. Manual for ways of coping questionnaire. - Palo Alto, CA: Consult. Psychol. Press, 1988. Methodology adaptation: Wasserman L.I. 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. Methodology for psychological diagnostics of ways of coping with stress and problem situations for the individual / Manual for physicians and medical psychologists. - V.M. Bekhterev St. Petersburg Research Psychoneurological Institute Publishing House. - St. Petersburg, 2009. - 40 p.

Type (underline):

- assessment scale

- score

- questionnaire

- other (specify):

Purpose: the questionnaire is widely used in domestic research to study stress coping behavior (coping behavior). The theoretical basis of the questionnaire is the transactional model of stress adaptation by R. Lazarus (1966).

The questionnaire includes 50 statements combined into 8 scales (obtained based on 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, avoidance. Raw scores for each scale are calculated and converted into T-scores (percentiles) using a special formula. The set of obtained T-scores reflects the individual structure (repertoire) of stress-coping behavior, and the highest scores on one of the scales indicate the predominance of the corresponding coping strategy in a person's coping behavior.

Appendix G16. Melbourne Decision Making Questionnaire

Russian title: Melbourne Decision Making Questionnaire.

Original title: Melbourne decision making questionnaire - (MDMQ).

Source (official developer website, validation publication):

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. Methodology adaptation: 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. - P. 74-86; Kornilova T.V. Melbourne Decision Making Questionnaire: Russian-language adaptation // Psychological Studies. - 2013. - Vol. 6. - No. 31.

Type (underline):

- assessment scale

- score

- questionnaire

- other (specify):

Purpose: the methodology is a personality questionnaire aimed at diagnosing individual decision-making styles. The questionnaire is the result of testing the broader 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.

Approximate testing time is 5-10 minutes.

The Melbourne Decision Making Questionnaire includes 22 statements, the agreement with which is assessed by the respondent on a 3-point scale. It allows diagnosing four properties interpreted as productive (vigilance) and unproductive coping (avoidance, procrastination, and hypervigilance) in decision-making situations.

Appendix G17. Questionnaire of Neurotic Personality (KON-2006)

Russian title: Neurotic Personality Questionnaire (KON-2006)

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

Source (official developer website, validation publication): Aleksandrowicz J., Klasa K., Sobanski J., Stolarska D. Kwestionariusz osobowosci nerwicowej KON - 2006, Komitet Redakcyjno-Wydawniczy Polskiego Towarzystwa Psychiatrycznego, Biblioteka Psychoterapii Polskiej, Krakow, 2006, p. 72. Methodology adaptation: Isurina G.L., Trabczynski P.K., Saint Petersburg State University, Faculty of Psychology Comparative study: Isurina G.L., Grandilevskaya I.V., Trabczynski P.K. «KON-2006 Questionnaire - a new method for studying neurotic personality traits» / Medical Psychology in Russia: electronic scientific journal. - 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-2006». - Methodological recommendations. - St. Petersburg - 2018 - 62 p.

Type (underline):

- assessment scale

- score

- 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 provides an opportunity to assess the degree of personality dysfunctions. Changes in this indicator occurring during the treatment process also make it possible to evaluate the impact 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 G18. 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):

- assessment scale

- score

- 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 the quantitative assessment of treatment adherence is proposed and recommended for inclusion in the standard medical examination program for individuals with chronic diseases. It can be used to identify patient cohorts in need of additional attention as insufficiently adherent to treatment. KOP-25 characteristics: sensitivity - 93%, specificity - 78%, reliability - 94%.

The questionnaire is filled out by the respondent personally or with the participation of an interviewer, including 25 questions with response options. It is filled out sequentially - from question 1 to question 25. For each question, the respondent chooses the most appropriate answer from the proposed closed list of 6 possible options. Only one answer can be chosen for each question of the questionnaire. 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 drug therapy», «importance of medical support», «importance of lifestyle modification» and «readiness for drug therapy», «readiness for medical support», «readiness for lifestyle modification». Each technical indicator is a simple sum of points obtained from answers to the corresponding questions. The minimum possible value of 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 G19. Experiences in Close Relationships Questionnaire by C. Brennan and R.C. Fraley

Russian title: Experiences in Close Relationships Questionnaire by Brennan and R.C. Fraley (adaptation by T.V. Kazantseva, 2008).

Original title: Experiences in Close Relationships-Revised - (ECR-R) (Brennan K., Fraley R., 2000).

Source (official developer website, validation publication):

Fraley R.C., Waller N.G., Brennan K.A. An item-response theory analysis of self-report measures of adult attachment // Journal of Personality and Social Psychology. 2000. No. 78. P. 350-365. Methodology adaptation: Kazantseva T.V. Adaptation of the modified methodology «Experiences in Close Relationships» by K. Brennan and R.C. Fraley // Izvestia RGPU im. A.I. Herzen. No. 34 (74): Postgraduate Student Notebooks. Part IP (Pedagogy, psychology, theory and methodology of teaching). St. Petersburg, 2008. P. 139-144.

Type (underline):

- rating scale

- index

- questionnaire

- other (specify):

Purpose: The questionnaire is designed to assess individual characteristics of adults in attachment relationships. The test result consists of two scales: attachment-related anxiety scale and attachment-related avoidance scale.

The test contains 36 statements that make up two scales: the attachment-related anxiety scale (i.e., the level of confidence or insecurity in the reliability and responsiveness of a significant other) and the attachment-related avoidance scale (i.e., the degree of discomfort experienced during psychological closeness with another person and the development of dependence on them).

High scores on both scales indicate a secure attachment style, while low scores indicate a fearful style. High scores on the anxiety scale and simultaneously low scores on the avoidance scale describe a preoccupied (anxious) style. High scores on the avoidance scale and simultaneously low scores on the anxiety scale describe a dismissing-avoidant attachment style.

Appendix G20. Adverse Childhood Experiences (ACE) Questionnaire

Russian title: Adverse Childhood Experiences (ACE) Questionnaire

Original title: Adverse Childhood Experiences - (ACE) (Anda R.F., Felitti V.J., 1998, 2004).

Source (official developer website, validation publication):

Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study / Felitti V.J., Anda R.F., Nordenberg D., Williamson D.F., Spitz A.M., Edwards V., Koss M.P., Marks J.S. // American Journal of Preventive Medicine. 1998. May; Vol. 14 (4). P. 245-258. Adverse Childhood Experiences (ACEs). - Available at: http://www.cdc.gov/violence prevention/acestudy/ (accessed 23 September 2017). Katan E.A. [Using the international adverse childhood experiences questionnaire to identify psychotraumatic factors in childhood and adolescence] // Medical Psychology in Russia. - 2019. - Vol. 11, no. 2. - P. 8. doi: 10.24412/2219-8245- 2019-2-8

Type (underline):

- rating scale

- score

- questionnaire

- other (specify):

Purpose: a screening questionnaire designed to measure types of childhood maltreatment or trauma. Applicable for individuals aged 18 years and older across all populations.

The original Adverse Childhood Experiences Questionnaire (ACE) was initially developed by V.J. Felitti for the Kaiser Permanente Center for Disease Control and Prevention. It currently has more than 10 modifications.

The ACE questionnaire is a self-report scale, meaning it is completed by the subject/patient. The questionnaire includes two groups of questions: a) questions aimed at assessing experiences of abuse and neglect; b) questions aimed at assessing experiences of other household dysfunction.

The test questions are divided into 10 categories: psychological, physical, and sexual abuse, emotional neglect, physical neglect, parental divorce, witnessing physical violence against the mother, alcoholism and/or drug addiction in the family, mental illness and/or suicide attempts among family members, and incarceration of family members.

When analyzing the data obtained using this questionnaire, one can consider both the total ACE score and the presence/absence of adverse childhood experiences for each of the 10 categories.

If a respondent answers positively to at least one question in a category, it is concluded that they have experienced this type of adverse experience.

As the total ACE score increases, the likelihood of developing social and emotional problems, psychosomatic diseases, and mental disorders increases, particularly the risk of developing panic disorder.

The most common modified version of the original ACE questionnaire is the WHO Adverse Childhood Experience International Questionnaire (ACE-IQ). In addition to the 10 core ACE factors, the ACE-IQ includes 3 groups of factors defining community and peer violence: at the micro-social level – peer victimization (bullying - B), witnessing violence in a peer group (collective violence - CV), and at the societal level, including wars, political and ethnic conflicts, and violent acts by organized criminal groups – community violence (CoV). Currently, the ACE-IQ questionnaire is undergoing validation testing.

Appendix G21. Conclusion (template) based on the results of experimental psychological examination (EPE).

Full name:

Date of birth:

Examination date:

Purpose of the examination: describe the goals set for the psychologist in conducting the EPE.

Research methods: describe the methods used during the EPE.

Complaints: describe the complaints presented by the examined patient.

Results of the clinical and psychological examination: ease of establishing contact, interest in the examination, emotional background, speech speed, voice volume, pace of work, performance level, speed of psychomotor reactions, how quickly and accurately instructions are understood and assimilated, and other personality traits demonstrated by the patient.

Results of the experimental psychological examination:

Attention: describe the results obtained using attention testing methods, indicating the severity of impairments (if identified).

Memory: describe the results obtained using memory testing methods, indicating the severity of impairments (if identified).

Thinking: describe the results obtained using thinking assessment methods, indicating the severity of impairments (if identified). When describing thinking, all 3 components of thinking must be described (B.V. Zeigarnik): the operational, dynamic, and motivational-personal components.

Emotional and volitional sphere: describe the results of studying the emotional and volitional sphere (level of situational and trait anxiety, severity of depressive symptoms, locus of control, level of social frustration, etc.).

Personality: describe the results of studying various personality traits of the patient (character accentuations, self-esteem level, type of internal conflict, adaptation resources, coping strategies and psychological defense mechanisms, adherence level and type of attitude towards illness, social orientation, etc.).

Conclusions: conclusions should briefly reflect the specific results obtained during the examination and provide quantitative and qualitative characteristics of the identified impairment(s).

Conclusion: describe the generalized characteristics and classification of impairments in accordance with the existing classification of pathopsychological symptom complexes.

Recommendations: outline recommendations indicating psychological "targets" for subsequent psychocorrection of impaired processes, states, or personality traits; determine the need for: 1) re-evaluating mental processes and emotional state via follow-up EPE; 2) conducting psychocorrectional and psychotherapeutic work (in individual, group, or family formats).