List of Abbreviations
GAD – generalized anxiety disorder
IAT – integrative anxiety test
ICD – International Classification of Diseases
MRI – magnetic resonance imaging
PAS – psychoactive substances
RCT – randomized clinical trials
SSRI – selective serotonin reuptake inhibitors
SNRI – serotonin-norepinephrine reuptake inhibitors
ACD – adequacy of evidence level
グレード – strength of recommendation level
BAI – (The Beck Anxiety Inventory) – Beck Anxiety Inventory
CGI – (Clinical Global Impression Scale) – Clinical Global Impression scale
COPE – (Coping) – coping orientation to problems experienced
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) – Ich Struktur Test nach G. Ammon, I. Burbiel
LSI – (Life style index) – Life Style Index
MDMQ – (Melbourne Decision Making Questionnaire) – Melbourne Decision Making Questionnaire
MMPI – (Minnesota Multiphasic Personality Inventory) – Minnesota Multiphasic Personality Inventory
MPS – (Multidimensional Perfectionism Scale) – Multidimensional Perfectionism Scale
SCL-90-R – (Symptom Check List-90-Revised) – Symptom Checklist-90-Revised
ShARS – (Sheehan Anxiety Scale) – Sheehan Anxiety Scale
STAI – (State-Trait Anxiety Inventory) – Spielberger-Hanin Anxiety Inventory
Terms and Definitions
Anxiety – a negatively valenced emotion expressing a sense of uncertainty, anticipation of negative events, and hard-to-define premonitions. Unlike the causes of fear, the causes of anxiety are usually not consciously recognized, but it prevents a person from engaging in potentially harmful behavior or prompts them to take actions to increase the likelihood of a favorable outcome.
Psychopharmacotherapy – the use of psychotropic medications in the treatment of mental disorders.
Psychotherapy – a system of therapeutic intervention on the human psyche, and through the psyche and by means of it, on the entire human body.
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Generalized anxiety disorder (GAD) is characterized by persistent and excessive anxiety and worry that are not restricted to, or predominantly provoked by, any particular environmental circumstances ("free-floating anxiety"). The condition follows a chronic or recurrent course and may lead to marked social dysfunction and an increased suicide risk. The duration of the anxiety state is at least 6 months and is not amenable to conscious control—meaning it cannot be suppressed by willpower or rational arguments—while the intensity of the anxiety is disproportionate to the patient's actual life situation [1,2,3].
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
Risk factors for the development of GAD include [4,5,6,7]:
personality traits—cautious behavior in unfamiliar situations, negative affectivity and hypervigilance, and avoidance of potential real or imagined harm are factors associated with GAD.
social factors—although overprotective parenting and adverse childhood experiences are more frequently reported among patients with GAD, no specific psychosocial factor has been definitively linked to the onset of GAD to date.
genetic and physiological factors—GAD is classified as a polygenic multifactorial disorder, and research into genetic polymorphisms (multiple genetic variants) responsible for the onset of GAD is actively ongoing. Genetic factors account for approximately 30% of the variance in GAD; however, these same genetic factors also determine negative affectivity and influence the manifestation of other affective disorders, particularly depression. Genetic risk is estimated to be twice as high in women as in men.
GAD remains the least studied of all anxiety disorders due to high comorbidity with other mood disorders. Current data suggest a role for noradrenergic hyperfunction and low benzodiazepine receptor density in the pathogenesis of GAD. The involvement of the immune system is also being investigated, given that persistent anxious rumination may promote cytokine release and sustain "smoldering inflammatory processes" in the body.
Among psychological theories of GAD, the metacognitive model is one of the most popular. According to this model, metacognitive functioning in GAD patients—which involves monitoring and evaluating one's own cognitive processes—is dominated by the belief that excessive worry and catastrophic scenarios serve a protective and reality-controlling function. The fact that most negative scenarios regarding the future do not materialize is interpreted in this context as proof of the protective role of worry and is positively reinforced, thereby maintaining adherence to the anxious metacognitive model.
The psychodynamic approach suggests that early experiences of deprivation by a significant other who embodies safety, combined with the absence of a stable attachment model or the predominance of an anxious attachment style in early childhood, lead to a lack of basic felt security and structural deficits within the personality. This predisposes the individual to free-floating, unfabricated anxiety rather than situational anxiety, along with difficulties in differentiating mental from somatic sensations and in regulating affective tension, ultimately creating a predisposition for the manifestation of GAD.
1.3 Epidemiology of the Disease or Condition
Lifetime prevalence of GAD ranges from 0.1% to 8.5%, with a mean of approximately 5% in the adult population. It constitutes a substantial proportion of all anxiety disorders—from 12% to 25%. It is more common in women, with a female-to-male ratio of 3:1. Current prevalence of GAD is estimated between 2% and 3%. Onset most frequently occurs between the ages of 21.1 and 34.9 years [8,9,10,11,12,13]. Data on the prevalence of GAD in Russia are lacking, but the diagnosis of GAD is made significantly less often than in foreign countries [133,140,224].
1.4 Features of Coding the Disease or Condition
F41.1 – Generalized anxiety disorder
1.5 Classification of the disease or condition
Classification of GAD [3]:
Chronic generalized anxiety disorder
Recurrent generalized anxiety disorder
1.6 Clinical presentation of the disease or condition
Generalized anxiety:
- lasts for at least 6 months;
- affects various aspects of the patient's life, circumstances, and activities;
- is primarily focused on future events;
- is uncontrollable and cannot be suppressed by willpower or rational arguments;
- is disproportionate to the patient's actual life situation;
- is frequently accompanied by feelings of guilt.
The clinical presentation is characterized primarily by three groups of GAD symptoms [2,14,15,16,17,18,19,20,21]:
Worry and apprehension that the patient finds difficult to control and that persist longer than usual. This worry is diffusely generalized and not focused on specific concerns, such as the fear of panic attacks (as in panic disorder), embarrassment in social situations (as in social phobia), or contamination (as in obsessive-compulsive disorder).
Other psychological symptoms of GAD include irritability, hypervigilance, concentration difficulties, and noise sensitivity (hyperacusis).
Muscle tension, which may manifest as tremor, inability to relax, increased muscle tone (causing pain in various locations), headaches (typically bilateral and often frontal or occipital), aching muscle pain, and muscle stiffness, particularly in the back and shoulder regions [1,21,22].
Autonomic nervous system hyperactivity, manifested by excessive sweating, tachycardia, dry mouth, epigastric discomfort, dizziness, and other symptoms of autonomic arousal [1,21,22].
Table 1.
Characteristic features of GAD
Factors indicating a more favorable prognosis: older age at onset; mild social dysfunction; female gender (women are more prone to remission) [2,10,12,14].
Factors indicating an unfavorable prognosis: poor marital or familial relationships; presence of comorbid psychiatric disorders; male gender (men are less prone to remission) [2,10,12,14].
Comorbidity is a hallmark of GAD. Over 90% of all patients with a primary diagnosis of generalized anxiety disorder have had another psychiatric disorder at some point in their lifetime [2,22,23,26,27,29].
The most frequently comorbid psychiatric disorders include:
- depressive episode, recurrent depressive disorder;
- bipolar affective disorder;
- dysthymia;
- specific phobias;
- social phobias;
- personality disorders in adults;
- obsessive-compulsive disorder;
- alcohol and other psychoactive substance (PAS) dependence;
- psychopathologically undifferentiated chronic fatigue syndrome.
There is a high prevalence of certain somatic diseases in patients with anxiety disorders [2,21,22]:
- cardiovascular diseases;
- gastrointestinal diseases;
- respiratory disorders;
- migraine;
- allergic diseases;
- metabolic syndrome;
- chronic pain syndrome.
In all patients with GAD, differential diagnosis with other psychiatric disorders and somatic diseases is recommended to confirm the diagnosis [1,2,17, 22,23,25,27,28].
GR CLEL 5Grade of Recommendation C (Level of Evidence – 5).
Comment: GAD must be differentiated from the following disorders:
- social phobias;
- specific phobias;
- obsessive-compulsive disorder;
- post-traumatic stress disorder;
- panic disorder;
- mood (affective) disorders (depressive episode, recurrent depressive disorder, bipolar disorder, dysthymia);
- somatoform disorders;
- schizophrenia (paranoid), schizotypal disorder;
- personality disorders in adults (histrionic, anankastic, anxious, emotionally unstable);
- residual organic brain disorders;
- organic brain diseases;
- hypothalamic disorder;
- thyroid pathology;
- pheochromocytoma;
- psychoactive substance use (e.g., amphetamines, cocaine, etc.);
- benzodiazepine derivative withdrawal;
- pharmacotherapy side effects (e.g., systemic corticosteroids, sex hormones, psychostimulants and nootropics, cardiovascular medications).
2. Diagnostics, medical indications and contraindications for diagnostic methods
Criteria for establishing the diagnosis/condition (ICD-10 research diagnostic criteria):
A. Presence for at least 6 months of prominent non-delusional anxiety, inner tension, hypervigilance, anxious ruminations, and negative future-oriented expectations
B. At least four of the following symptoms must be present, with at least one from items 1–4:
1) pounding or accelerated heart rate;
2) sweating;
3) tremor or shaking;
4) dry mouth (not due to medication or dehydration);
Somatic symptoms:
5) difficulty breathing;
6) feeling of choking;
7) chest pain or discomfort;
8) nausea or abdominal distress (e.g., burning in the stomach, diarrhea, flatulence);
Mental status symptoms:
9) feeling dizzy, unsteady, or faint;
10) feelings that objects are unreal (derealization) or that one's self is distant or "not truly here";
11) fear of losing control, going crazy;
12) fear of dying;
General symptoms:
13) hot flashes or chills;
14) numbness or tingling sensations;
Tension symptoms:
15) muscle tension or aches;
16) restlessness and inability to relax;
17) feeling jittery, keyed up, or mentally strained;
18) sensation of a lump in the throat or difficulty swallowing;
Other non-specific symptoms:
19) exaggerated startle response to minor unexpected stimuli;
20) difficulty concentrating or "mind going blank" due to worry or anxiety;
21) persistent irritability;
22) difficulty falling asleep due to worry.
C. The disorder does not meet the criteria for panic disorder (F41.0), phobic anxiety disorders (F40.-), obsessive-compulsive disorder (F42-), or hypochondriacal disorder (F45.2).
D. Most commonly used exclusion criteria. The anxiety disorder is not attributable to a somatic condition such as hyperthyroidism, an organic mental disorder (F00-F09), or a psychoactive substance-related disorder (F10-F19), such as excessive use of amphetamine-like substances or benzodiazepine withdrawal.
2.1 Complaints and Anamnesis
Algorithm for the diagnosis and management of patients with GAD is provided in Appendix B.
When interviewing all patients presenting with complaints of generalized anxiety, it is recommended to assess both affective anxiety symptoms and somatic manifestations of anxiety in order to identify psychological and somatic anxiety components to be considered when selecting therapy [21,231].
GCR CLEL 4Grade of Recommendation C (Level of Evidence – 4).
When taking a history and conducting a clinical interview in all patients presenting with complaints of anxiety, it is recommended to identify symptoms of persistent (generalized) and difficult-to-control anxiety in the mental status for differential diagnosis from other conditions [1,2,14,23,231].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
When taking a medical history in all patients presenting with complaints of generalized anxiety, it is recommended to assess the duration of anxiety states (at least 6 months for generalized anxiety disorder) for differential diagnosis from other conditions [1,2,14,23,231].
GR CLEL 5Grade of Recommendation C (Level of Evidence – 5).
When interviewing all patients with generalized anxiety, it is recommended to isolate complaints related to persistent autonomic manifestations of anxiety in order to identify diagnostic criteria and account for them when selecting therapy [17,21,231].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
When interviewing and taking a history in all patients with generalized anxiety, it is recommended to identify potential comorbid psychiatric disorders (including post-traumatic stress disorder, depressive and bipolar disorders, psychoactive substance dependence) for differential diagnosis and to account for them when selecting therapy [23,24,27,29,231].
GR CLEL 5Grade of Recommendation C (Level of Evidence – 5).
Comment: generalized anxiety is frequently observed within the context of other psychiatric disorders. If criteria for post-traumatic stress disorder, depressive or bipolar disorder, or psychoactive substance dependence are met, it is more appropriate to evaluate generalized anxiety in these patients as a symptom of the aforementioned disorders.
When interviewing and taking a history in all patients with generalized anxiety, it is recommended to identify potential comorbid somatic pathology for differential diagnosis and to account for it when selecting therapy [23,24,27,29].
GR CLEL 5Grade of Recommendation C (Level of Evidence – 5).
Comment: GAD is frequently observed in somatic disorders. If criteria for a somatic disease are identified, it is more appropriate to evaluate GAD in these patients as a comorbid or secondary disorder.
When taking an anamnesis in all patients with generalized anxiety, it is recommended to identify current stressors in the patient's life, recent breakup experiences, interpersonal problems, ongoing doubts and concerns, as well as instances of suicidal behavior [23,24,27,29].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
When taking a history in all patients with generalized anxiety, it is recommended , whenever possible, to corroborate the obtained information with objective data from the patient's relatives to ensure greater diagnostic accuracy [23,24,27,29].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
When taking a history in all patients with generalized anxiety, it is recommended to assess suicide risk in order to determine the type and scope of psychiatric care required [23,24,27,29]
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
2.2 Physical Examination
All patients with generalized anxiety are recommended to undergo a standard physical and neurological examination to rule out somatic and neurological causes of autonomic symptoms [2,18,30,31]
GRL CLEL 4Recommendation Grade C (Level of Evidence – 4).
All patients with generalized anxiety are recommended to undergo a physical examination, external inspection, measurement of height, body weight, level of physical development, and assessment of skin integrity in order to rule out somatic diseases, identify signs of self-harm (taking into account their recency), and evaluate somatic status [2,18,30,31].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
All patients with generalized anxiety are recommended to undergo palpation of the thyroid gland and confirm the absence of exophthalmos to rule out thyroid disorders [2,14].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
All patients with generalized anxiety are recommended to have their pulse and blood pressure measured in the supine position (after resting for 5 minutes) and standing (3 minutes after standing up) to assess autonomic manifestations and somatic status [2,18,22].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
For all patients with generalized anxiety, the physical examination is recommended to include screening for injection marks of varying ages in order to detect the use of psychoactive substances (PAS) or medications that may induce anxiety symptoms [18,30,31]
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
2.3 Laboratory Diagnostics
There are no specific laboratory methods for diagnosing GAD. The primary purpose of laboratory testing is to rule out somatic conditions that may present with symptoms similar to GAD.
All patients with generalized anxiety are recommended to undergo a general (clinical) urinalysis, a complete blood count including hemoglobin, hematocrit, erythrocyte, leukocyte, and platelet counts, and erythrocyte sedimentation rate as part of the initial assessment, upon hospital admission, and during follow-up monitoring to determine the degree of disease activity and diagnose organ and system involvement [2,16,22,30,98,99,100].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
All patients with generalized anxiety are recommended to undergo a general clinical 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 activity, C-reactive protein) as part of the initial assessment, upon hospital admission, and during follow-up monitoring to evaluate renal and hepatic function and rule out inflammation [2,14,16,22,30,98,101].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
All patients with generalized anxiety are recommended to undergo testing for hepatitis B virus surface antigen (HbsAg) in the blood, antibodies to hepatitis C virus (Hepatitis C virus) in the blood, antibodies to Treponema pallidum in the blood, IgM and IgG antibodies to human immunodeficiency virus HIV-1 in the blood, and IgM and IgG antibodies to human immunodeficiency virus HIV-2 in the blood as part of the initial assessment, upon hospital admission, and subsequently every 12 months to rule out association with HIV infection, hepatitis, and syphilis [14,16,30,101].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).
All patients with generalized anxiety are recommended to undergo blood testing to assess thyroid function: [2,14]: measurement of serum total triiodothyronine (T3), serum free triiodothyronine (T3), serum total thyroxine (T4), serum free thyroxine (T4), and blood thyroid-stimulating hormone levels to rule out thyroid pathology [2,14,16,22,30,101].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).
Comment: Thyroid hormone level screening is recommended for first-time patients who have never undergone this test before, or in the presence of clinical or anamnestic indications.
Comment: The primary goal of laboratory tests is to rule out somatic diseases that may present with symptoms similar to GAD.
2.4 Instrumental Diagnostics
Currently, there are no instrumental diagnostic methods for GAD
In patients with generalized anxiety in whom history-taking, physical and neurological examinations, and laboratory results fail to reliably rule out paroxysmal states, electroencephalography is recommended to assess cerebral bioelectric potentials and rule out this pathology [2,14,16,22,30,102].
GPP CLOE 4Grade of Recommendation C (Level of Evidence – 4).
In patients with generalized anxiety with a history of syncope and in individuals in whom history-taking, physical and neurological examinations, and laboratory results fail to reliably rule out cerebrovascular disorders, transcranial duplex scanning of arteries and veins is recommended to rule out this pathology [2,14,16,22,30,103].
GCR BLEL 3Grade of Recommendation B (Level of Evidence – 3).
In patients with generalized anxiety with a history of traumatic brain injury, suspected brain tumors, headaches, or in whom history-taking, physical and neurological examinations, and laboratory results fail to reliably rule out organic brain damage, brain magnetic resonance imaging (MRI) is recommended to rule out this pathology [2,14,16,22,30,104].
GPP BLOE 3Grade of Recommendation B (Level of Evidence – 3).
All patients with generalized anxiety are recommended to undergo electrocardiography to assess somatic status, objectify autonomic cardiovascular dysfunction (palpitations, sensations of skipped beats in the heart area), and rule out cardiovascular pathology [2,14,16,22,30,105].
GPP BLOE 3Grade of Recommendation B (Level of Evidence – 3).
2.5 Other Procedures
Patients with GAD who require scaled assessment of their condition and identification of psychotherapy targets are recommended to undergo a specialized psychological evaluation, including: 1) clinical and psychological psychodiagnostic assessment (individual clinical and psychological counseling) (A13.29.003.001) and 2) pathopsychological experimental-psychological (psychodiagnostic) study (B03.035.004) [231,232].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
Comment: GAD is a disorder whose pathogenesis and clinical (clinical-psychopathological) manifestations are heavily influenced by psychological factors, and psychotherapy is one of the effective treatment methods. Based on the biopsychosocial concept of understanding mental disorders, it is important to involve medical psychologists in multidisciplinary teams to conduct experimental psychological diagnostics, which, within a personalized approach, allows determining the individual psychological characteristics of the patient, identifying targets for psychotherapeutic intervention, and objectifying the dynamics of therapeutic measures [1,2,3,34]. At the same time, psychological diagnostics is one of the most crucial components of a medical psychologist's involvement in providing medical care to patients with GAD. All main types, methods, and techniques accepted both in psychological diagnostics in general and in its applied clinical branch, referred to as "medical psychodiagnostics" or "clinical psychological diagnostics," are used. In accordance with the basic theoretical tenets of psychological diagnostics, clinical practice utilizes both clinical-psychological (expert) methods (clinical interview, observation, conversation, analysis of activity products, etc.) and experimental-psychological methods. Questionnaire-based methods rely heavily on the self-report nature of the data obtained and have limitations regarding the objectivity of such data. On the other hand, they reflect to a greater extent the individual psychological characteristics of the personality itself and its preservation/alteration in the situation of illness, as well as revealing a wide range of inherent connections, relationships, coping and response styles, and other clinically significant personality and personality-environment interaction characteristics of the subject, etc. Such data should be evaluated within the framework of a personalized approach when 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 during the performance of tests and test batteries by the subject. A distinguishing feature of applying clinical and experimental psychological methods in solving psychological diagnostic tasks is the consideration and analysis of specifics caused by the disease-altered mental and psychological status of the subject.
Thus, when conducting a psychodiagnostic assessment of a patient with GAD as part of a clinical and psychological psychodiagnostic study, the following are applied:
Clinical rating scales;
Clinical-psychological and experimental-psychological methods and techniques (non-standardized patho- and neuropsychological tests, standardized psychometric test batteries).
Patients with generalized anxiety require the use of 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 picture of the disease, diagnostic, and therapeutic objectives.: The Hamilton Anxiety Rating Scale (HARS) (Appendix G1); To assess the severity of clinical manifestations, it is recommended to use the Symptom Check List-90-Revised (SCL-90-R) (Appendix G3); Integrative Anxiety Test (IAT) (Appendix G4); State-Trait Anxiety Inventory (STAI) (Appendix G5); The Beck Anxiety Inventory (BAI) (Appendix G6); Sheehan Anxiety Scale (ShARS) (Appendix G7) [1,2,3,34]; If rapid assessment of condition dynamics is necessary, the Clinical Global Impression scale (CGI) is used. The specified methods are psychometric and/or symptomatic questionnaires that allow for an objective assessment of the nature and severity of clinical symptoms, their dynamics, and the effect of ongoing treatment. A more comprehensive clinical-psychological and experimental-psychological diagnosis can be performed by a medical psychologist depending on specific diagnostic tasks or to determine the targets of psychotherapeutic intervention. An experimental-psychological examination is prescribed by the attending physician. The choice of methods and techniques for psychological diagnostics falls within the competence of a 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 carried out by a medical psychologist individually, depending on the tasks addressed regarding a specific patient. Various scales adapted and validated depending on the research objectives can be used. The methods proposed below are used on an optional basis, and the list of possible methods for 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 Inventory (MMPI) (adapted by Sobchik L.N. et al. (1970) – full version of MMPI) (Appendix G8) [2,22,124]; Ich Struktur Test nach G. Ammon ("I-Structure Test" by G. Ammon, 1978) (ISTA)) (Appendix G9) [2,22,125]. The most frequently used methods for studying individual psychological characteristics of personality: (Method for determining the level of subjective control of the personality (LSC) (Appendix G10) [2,22,126]; Personal Beliefs Test (Kassinove H., Berger A., 1984) (Appendix G11) [2,22,127]. The most frequently used methods for psychological diagnosis of risk factors for mental maladjustment: (Life Style Index (LSI) (Appendix G12) [2,22,128]; Ways of Coping Questionnaire by R. Lazarus (WCQ, Folkman S., Lazarus R., 1988) (Appendix G13) [2,34,129]. Melbourne Decision Making Questionnaire (MDMQ) (Appendix G14) [2,22, 130]. 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 G15) [2,22,131]. To study treatment adherence, the following method is used: Russian Universal Questionnaire for Quantitative Treatment Adherence (KOP-25) (Appendix G16) [2,22,132].
Psychological diagnostics is performed by a medical psychologist according to the following algorithm [142,143,144,145]:
Stage 1 – Clinical and psychological examination aimed at establishing a trusting relationship, assessing the patient's current emotional state and behavior, and their attitude towards the examination and treatment. Methods: observation, conversation, interview, life history analysis. The psychologist notes and subsequently records in the report based on the results of the experimental-psychological study (EPS): availability for contact, attitude towards the examination, understanding of instructions, interest in testing results, loudness and speed of speech, facial expressions, general emotional background, pace of psychomotor reactions, behavioral characteristics during the examination, and personal traits demonstrated by the patient.
Stage 2 – Experimental-psychological study (EPS). The objectives of the experimental-psychological examination are:
- differential diagnosis of disorders in the patient's mental activity;
- analysis of the structure and determination of the degree of impairment of mental processes, states, and personality properties;
- determination of the level of development 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 study, higher mental (cognitive) functions, as well as the patient's personal and emotional sphere, are studied, and a qualified expert assessment of the identified disorders is performed. Based on the results of the EPS, an expert report is drawn up (Appendix G21), and the expert psychologist provides recommendations that must be taken into account by specialist physicians in the treatment process [142,143,144].
The total duration of the psychological diagnostics procedure in a psychiatric clinic is 3-5 hours and includes 2 types: 1) Clinical-psychological psychodiagnostic examination (A13.29.003.001) and 2) Pathopsychological experimental-psychological (psychodiagnostic) study (B03.035.004) [145,146,147].
For patients with generalized anxiety, if screening is necessary, it is recommended to use the Generalized Anxiety Disorder-7 (GAD-7) screening questionnaire (Appendix G2) to assess the anxiety level [141,232].
GPP BLOE 3Grade of Recommendation B (Level of Evidence – 3).
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
3.1. Complex Therapy
For all patients with GAD, psychopharmacotherapy and/or psychotherapy is recommended for symptom relief [2,34,36,37,38,39,231].
GPP ALOE 1Grade of Recommendation A (Level of Evidence – 1).
Comment: data from modern scientific research confirm the efficacy of both psychopharmacotherapy and psychotherapy (cognitive-behavioral, dynamic, relaxation, etc., in the treatment of GAD). There are studies showing high efficacy of the combined use of psychopharmacotherapy and psychotherapy. The choice of treatment strategy and the ratio of psychopharmacotherapy to psychotherapy depend on clinical symptom manifestations, the stage of treatment, personality traits, patient attitudes and expectations, current resources, and organizational capabilities, and should be flexibly evaluated using a personalized approach in each specific case. There are indications and contraindications for both psychopharmacological and psychotherapeutic treatments. These are mainly related to the patient's condition, side effects, and organizational conditions. The advantages of psychotherapy include the absence of somatic side effects of treatment and, according to some studies, better preservation of achieved results. Disadvantages include higher cost, the need for weekly visits, and the critical importance of personal motivation and patient engagement in the treatment process. Psychopharmacotherapy requires fewer material and time resources, but quite frequently causes side effects, and symptom relapse is possible upon its discontinuation [15,17,27,34,35,36,40,41,42,43,44,45,46].
3.2. Psychopharmacotherapy
The algorithm for psychopharmacotherapy of generalized anxiety disorder is presented in Appendix B3.
First-line therapy
For all patients with GAD, as first-line medications, it is recommended to initiate therapy with drugs from the group of selective serotonin reuptake inhibitors (ATX classification code: N06AB06) (paroxetine** 20-40 mg/day, escitalopram 10-20 mg/day, #sertraline** 50-200 mg/day), or from the group of selective serotonin and norepinephrine reuptake inhibitors (ATX classification code: other antidepressants N06AX21) (#venlafaxine 75-225 mg/day, duloxetine 30-120 mg/day), or the melatoninergic antidepressant agomelatine** (25-50 mg/day) (ATX classification code: other antidepressants N06AX22) in order to reduce anxiety intensity and stabilize mood [33,34,35,36,47-53,77-80,106,107,109,138,139].
GPP ALOE 1Grade of Recommendation A (Level of Evidence – 1).
Comment:since randomized controlled trials (RCTs) conducted to evaluate the efficacy of drugs in the treatment of GAD did not take into account the specifics of clinical manifestations (dominance of certain symptom complexes, increase in hypochondriacal tendencies), there are certain difficulties in applying their results when implementing a personalized approach in medicine. After establishing a diagnosis of GAD, patients are recommended, as a first course for 4-6 weeks, either monotherapy with drugs from the group of selective serotonin reuptake inhibitors (paroxetine**, escitalopram, #sertraline**), or #venlafaxine or duloxetine, or agomelatine**. The treatment option should be chosen individually for each patient, taking into account the psychotropic and somatotropic effects of the drug, potential adverse events, the patient's mental and somatic status, and the clinical characteristics of the disease (see Table 4, Appendix A3). Antidepressant monotherapy starts with minimal dosages and is gradually titrated to therapeutic ones. The anxiolytic effect develops individually within 2-8 weeks. The advantages of this group of drugs include a favorable efficacy-tolerability-safety profile, the possibility of once-daily administration, and the availability long-term therapeutic effect; disadvantages include delayed onset of effect, possible anxiogenic effect during the first week of therapy, the need for dose titration, negative impact on sexual function, nausea, and other side effects. It is recommended to warn a patient with GAD about the possible development of side effects at the start of antidepressant therapy to ensure compliance. During the first weeks of administration, it is advisable to monitor the patient, assessing suicide risks and possible intensification of anxiety symptoms. When prescribing pharmacotherapy, the physician relies primarily on data regarding the evidence-based efficacy of the drug, its tolerability profile, as well as the physician's own clinical experience and qualifications [32, 137].
For GAD patients with pronounced anxiety and autonomic disorders at the first stage of therapy, it is recommended to use short-term preparations from the benzodiazepine derivative group for the purpose of relief of anxiety and autonomic symptoms [33,34,35,36,45,56,60,61,62,63,64,108,148,149,150].
GPP ALOE 1Grade of Recommendation A (Level of Evidence – 1).
Comment: among benzodiazepine derivatives, alprazolam [148,149,150], diazepam** [108,151,152,153,154], and lorazepam** [155] have been studied most thoroughly. The advantages of benzodiazepine derivatives are a rapid effect, good tolerability, a wide therapeutic window, and safety in case of overdose. Considering that the effect of antidepressants is achieved after 4-6 weeks of therapy, the short-term prescription of benzodiazepine derivatives at the first stage makes it possible to reduce the intensity of anxiety symptoms. Before prescribing this group of drugs, a thorough drug abuse history must be obtained. It is inexpedient to prescribe them to patients with dependence or the risk of developing a psychoactive substance 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 tend to exceed the recommended dosages. Drugs of the benzodiazepine derivative group can form dependence and have a withdrawal syndrome upon abrupt cessation of therapy. Therefore, the duration of their use should be limited to 3-4 weeks. The duration of use is also limited by significant adverse effects – sedation, dizziness, impaired coordination, decreased concentration and memory, impaired psychomotor functions, the risk of developing dependence and drug tolerance, and a pronounced withdrawal syndrome manifesting as worsening condition and increased anxiety after discontinuation; therefore, it should be limited to short courses (no more than 4 weeks). However, in cases of severe anxiety that is not relieved by antidepressants and/or is accompanied by pronounced autonomic disorders, the duration of benzodiazepine derivative prescriptions can be increased up to 6 months. There are no evidence-based studies on the efficacy of bromdihydrochlorphenylbenzodiazepine** in GAD. However, in Russian medical practice, it is traditionally used to treat anxiety disorders. When prescribing benzodiazepine derivatives, the half-life should be taken into account when deciding on the dosing frequency and for the prevention of accumulation effects (bromdihydrochlorphenylbenzodiazepine** is not recommended to be prescribed more than 1-2 times a day due to its long half-life; alprazolam should be prescribed at a frequency of at least 3 times a day due to its relatively short half-life).
Second-line therapy
In case of ineffectiveness of first-line therapy, second-line therapy is used – a dose increase of the antidepressant to the maximum therapeutic dose, switching the antidepressant to another from the list of first-line drugs not used in the first course of therapy, pregabalin** monotherapy, or adding benzodiazepine derivatives for a longer period (see Appendix B3).
In the absence of a sufficient effect of psychopharmacotherapy, it is recommended to verify proper patient compliance in order to confirm the fact of an insufficient therapeutic response to a specific drug [33,34,35,36,40,42,45].
Level CLevel 3Level of recommendation evidence C (reliability level of evidence – 3).
Comment: in case of ineffectiveness of the first course of therapy, it is first necessary to verify patient compliance, since non-adherence to the medication regimen is the cause of treatment resistance in a significant number of cases. Treatment non-adherence may be related to side effects, poor patient involvement in the therapeutic process, low motivation, or the perception of a lack of treatment effect (especially typical when taking antidepressants, the effect of which is delayed). To improve compliance, a psychoeducational discussion should be held with the patient, discussing potential side effects, the need for regular medication intake, and the gradual development of the therapeutic effect of antidepressants. Compliance psychotherapy or motivational interviewing may be used additionally. Keeping a medication diary or using a smartphone app with reminders plays a positive role.
In case of partial symptom reduction with selective serotonin reuptake inhibitors (paroxetine**, escitalopram, and #sertraline**), #venlafaxine, duloxetine, or agomelatine, it is recommended to titrate the drug dose to the maximum recommended (tolerated) level and continue the course of therapy for another 4-6 weeks in order to achieve complete reduction of clinical symptoms of GAD [33,34,36,40, 45,47,49,54].
Level of Evidence BLevel of Confidence 2Level of recommendation B (level of evidence – 2).
For GAD patients with dominant somatic equivalents of anxiety in the clinical picture, at the second stage, it is recommended to use pregabalin** monotherapy (150-600 mg/day) (pharmacotherapeutic group: antiepileptic drugs; ATX code: N03AX16) to reduce anxiety and the intensity of somatic manifestations [33,34,35,36,45,46,54,55,56,57,58,59].
GPP ALOE 1Grade of Recommendation A (Level of Evidence – 1).
Comment: The anxiolytic effect of pregabalin**, its impact on the psychological, somatic, and autonomic components of anxiety, as well as its good tolerability and high level of safety, have been thoroughly studied and confirmed in meta-analyses across several evidence-based studies. The anxiolytic effect of pregabalin** is achieved during the first week of administration. Unlike most antidepressants, pregabalin** does not inhibit cytochrome P450 enzymes, has no drug-drug interactions with other medications (e.g., warfarin**), and can be used in GAD patients with chronic somatic diseases. Pregabalin** should not be prescribed to patients prone to dependence or already suffering from various forms of psychoactive substance dependence. Such patients exhibit cross-dependence and a more rapid increase in tolerance. A thorough drug abuse history of the patient is recommended to minimize the risk of developing dependence [33,34,35,36,45,46,54,55,56,57,58,59].
Third-line therapy
If second-line therapy is ineffective, third-line therapy is used, which involves various drugs that have been less studied in GAD or have worse tolerability than first- and second-line drugs, or combination therapy (see Appendix B3). Second-line drugs include #imipramine**, hydroxyzine**, #quetiapine**, marituperdin (according to WHO nomenclature) (2,8-dimethyl-5-(2-phenylethyl)-2,3,4,5-tetrahydro-1H-pyrido[4,3-b]indole hydrochloride), buspirone, or combination therapy. Any of these options can be chosen by the physician in case of ineffectiveness or poor tolerability of first- and second-line drugs.
In the absence of a therapeutic effect with selective serotonin reuptake inhibitors, #venlafaxine/duloxetine, or pregabalin**, it is recommended to use combination antidepressant therapy (selective serotonin reuptake inhibitors (#venlafaxine/duloxetine) and pregabalin** (150-600 mg/day)) [45,54,55,57,58,59,60,156]
GCR BLOCE 2Level of recommendation validity B (Level of evidence – 2).
In the absence of a therapeutic effect during therapy with selective serotonin reuptake inhibitors, #venlafaxine/duloxetine, or pregabalin**, it is recommended to switch drug therapy to #imipramine** (ATX code: N06AA02) at doses of 75-200 mg/day [45,47,49,108].
GCR BLEL 2Grade of Recommendation B (Level of Evidence – 2)
Comment: Therapy with non-selective monoamine reuptake inhibitors (tricyclic antidepressants) should be carried out under close specialist monitoring due to the risk of adverse drug reactions (weight gain, orthostatic hypotension, tachycardia, anticholinergic side effects, etc.). In addition, drug overdose can be fatal. It is undesirable to prescribe non-selective monoamine reuptake inhibitors in older age [34,35,40,41,43,47,53,157].
For patients with GAD in whom antidepressant therapy or its combination with benzodiazepine derivatives is ineffective, the atypical antipsychotic #quetiapine** (ATC code: N05AH04) is recommended at an initial dose of 50 mg/day, with an increase to 150 mg/day by the third day of therapy and a maximum dose of 300 mg/day by weeks 3–4 of treatment [34,45,65,66,67,110,158,159,160,161,162].
GoR ALoE 2Grade of Recommendation A (Level of Evidence – 2).
Comment: Most studies have investigated the efficacy of antipsychotic drugs for GAD when combined with antidepressants to increase therapeutic efficacy. According to several RCTs, the use of extended-release #quetiapine** as monotherapy or as an adjunct to an antidepressant for the treatment of GAD is acceptable at dosages up to 300 mg/day, although the therapeutic range of 50–150 mg/day proved to be the most effective [67,110,158,159,160,161,162]. With prolonged use of #quetiapine**, the metabolic side effects of the drug should be kept in mind.
For patients with GAD, for the relief of anxiety symptoms in cases of refractoriness to first- and second-line drugs, hydroxyzine** (anxiolytic agent; ATC code: N05BB01) (50–100 mg/day) is recommended [73,74,163,164,165].
GCR ALEL 1Grade of Recommendations A (Level of Evidence – 1)
Comment: Hydroxyzine** is an antihistamine well-studied in anxiety disorders, possessing a moderately pronounced sedative effect. There is a lack of convincing data on the efficacy and tolerability of long-term use of the drug.
For patients with GAD, for the relief of clinical symptoms of anxiety in cases of refractoriness to first- and second-line drugs, the use of buspirone (15–60 mg/day) (anxiolytic agent, ATC code: N05BE01) is recommended [73,75,76,148,166,167,168].
GRC BLEL 2Grade of Recommendation B (Level of Evidence – 2)
Comment: Buspirone is a 5-HT1A serotonin receptor agonist, studied in 7 RCTs, three of which showed no difference from placebo. The long-term effects and relapse-prevention action of the drug are poorly studied.
For patients with GAD, for the relief of clinical symptoms of anxiety in cases of refractoriness to first- and second-line drugs, the use of marituperdine (according to WHO nomenclature) (2,8-dimethyl-5-(2-phenylethyl)-2,3,4,5-tetrahydro-1H-pyrido[4,3-b]indole hydrochloride) (40 mg/day) (pharmacotherapeutic group – other anxiolytic agents, ATC code: N05BX) is recommended [169,170].
GRC BLEL 2Grade of Recommendation B (Level of Evidence – 2)
Comment: Marituperdine (2,8-dimethyl-5-(2-phenylethyl)-2,3,4,5-tetrahydro-1H-pyrido[4,3-b]indole hydrochloride) is a novel domestic anxiolytic agent with multi-receptor action [170]. Its antianxiety effect in GAD was demonstrated in a single placebo-controlled RCT [169]. The effect appeared starting from the first week of administration and was not accompanied by pronounced sedation or behavioral toxicity. The drug is well tolerated (dizziness, somnolence, and asthenia were most frequently noted at the start of treatment) and has no addictive potential. The long-term effects of marituperdine (2,8-dimethyl-5-(2-phenylethyl)-2,3,4,5-tetrahydro-1H-pyrido[4,3-b]indole hydrochloride) have not been studied.
Fourth-line therapy (treatment-resistant)
In cases where the first three stages of psychopharmacotherapy are ineffective, therapeutic resistance is present. To determine the causes of therapeutic resistance, it is necessary to clarify the diagnosis, identify comorbid disorders, perform additional examinations, and assess compliance. In resistant states, it is possible to combine various antidepressants with pregabalin**, buspirone, antipsychotics, #valproic acid**, or certain other poorly studied drugs, as well as to use longer courses of therapy with partial effect or monotherapy with other previously unused drugs having lower recommendation grades and evidence levels (see Appendix B3).
For patients with GAD in whom antidepressant therapy or its combination with benzodiazepine derivatives is ineffective, for the purpose of reducing anxiety levels, the prescription of the following second-generation antipsychotics, less often as monotherapy or more often in combination with antidepressants or anxiolytics, is recommended [33,34,35,36,45,65,66]:
#olanzapine** (ATC code: N05AH03) in combination with #fluoxetine** (pharmacotherapeutic group: SSRI antidepressants; ATC code: N06AB03) at an initial dose of 2.5 mg/day during the first week, 5 mg/day during the second week, and in case of ineffectiveness, a gradual (5 mg/day per week) dose increase to the maximum (20 mg/day) [112];
GRC BLEL 2Grade of Recommendation B (Level of Evidence – 2)
#aripiprazole (ATC code: N05AX12) (7.5–30 mg/day) [113,114];
GPP CLOE 4Grade of Recommendation C (Level of Evidence – 4).
#risperidone** (ATC code: N05AX08) in flexible doses from 0.5 to 1.5 mg/day [111];
GCR BLEL 2Grade of Recommendations B (Level of Evidence – 2)
Comment: #Risperidone** was studied in two placebo-controlled RCTs against the background of benzodiazepine tranquilizer use: one of them showed superiority over placebo [111], while the other – did not [171].
For patients with GAD, for the relief of anxiety symptoms in case of refractoriness to other types of pharmacotherapy, the use of #valproic acid** (pharmacotherapeutic group: antiepileptic drugs, ATC code: N03A) at a dose of 1500 mg/day, divided into three doses per day, is recommended [172].
Comment: A double-blind, placebo-controlled RCT demonstrated the efficacy of a 6-week course of #valproic acid** monotherapy (extended-release daily formulation) during GAD exacerbations. The most frequent side effects were dizziness and nausea. Long-term courses have not been studied, so their efficacy and tolerability are unknown. The use of #valproic acid** during pregnancy should be avoided.
For patients with GAD presenting with pronounced anxiety when antidepressant therapy or its combination with benzodiazepine derivatives is ineffective, for the rapid relief of anxiety as part of combination therapy, the symptomatic, short-term (until anxiety symptoms subside) prescription of certain first-generation antipsychotics in combination with antidepressants is recommended :
#chlorprothixene (15–100 mg/day) [65,70,71];
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
#sulpiride** (50–400 mg/day) [65,69,134];
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
alimemazine as part of combination therapy (20–80 mg/day) [68,72,235].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comment: There are no evidentiary studies regarding #alimemazine, #sulpiride**, and #chlorprothixene. However, in domestic medical practice, these drugs are traditionally used for the treatment of anxiety disorders [68,70,72]. Adjunctive therapy with antipsychotics must be carried out under careful medical supervision due to the development of undesirable side effects (dizziness, orthostatic hypotension, somnolence, weight gain, akathisia and other extrapyramidal symptoms, hyperprolactinemia, etc.). In view of the aforementioned side effects on the patient's part, the prescription of second-generation antipsychotics is preferable, since there is a high risk of non-compliance and refusal of psychopharmacotherapy [34,35,71].
For patients with GAD, for the relief of clinical symptoms of anxiety refractory to other types of pharmacotherapy, the use of certain other antidepressants is recommended: #clomipramine** (ATC code: N06AA04) at doses of 50–250 mg/day [109], #vortioxetine (ATC code: N06AX26) (2.5–10 mg/day) [81,135,136,173,174], #citalopram (ATC code: N06AB04) (20–30 mg/day) [47,175], #trazodone (ATC code: N06AX05) (150–400 mg/day) [82,108], #fluvoxamine (ATC code: N06AB08) (150–300 mg/day) [176,177], #fluoxetine** (ATC code: N06AB03) (20 mg/day) [112].
Level of Evidence BLevel of Confidence 2Level of recommendation B (level of evidence – 2).
Comment: #Citalopram was used only in elderly patients [47,175]. #Vortioxetine was studied in placebo-controlled RCTs, but outperformed placebo in only two of them [81,135,136,173,174]. #Fluvoxamine was studied only in generalized social anxiety disorder [176,177]. #Fluoxetine** was studied only in combination with #olanzapine** in patients with antidepressant resistance [112].
For patients with GAD, for the relief of psychological and somatic symptoms of anxiety, the use of fabomotizole (ATC code: N05BX) (30–60 mg/day) is recommended [115-119].
AG CLEL 2Recommendation Grade C (Level of Evidence – 2).
Comment: Fabomotizole in GAD has been evaluated in three small open-label randomized trials compared to benzodiazepine derivatives [115-117], in which it was not inferior in efficacy, as well as in a number of other open-label observational studies [118, 119, 230]. A systematic review confirmed the efficacy of the drug in reducing anxiety levels with a course duration of therapy of 6 weeks and doses of 30-60 mg/day, and it is especially indicated for patients with moderately severe anxiety and anxiety-asthenic disorders with a simple structure [119]. A sustained-release extended-release dosage form of fabomotizole with a once-daily dosing regimen is available [229]. Long-term therapy with fabomotizole has not been specifically studied in RCTs, but the drug is available over-the-counter and its widespread use in practice, including in somatic patients, has demonstrated its good tolerability and safety [119]. The drug does not cause clinically significant adverse effects, cognitive impairment, habituation, dependence, or withdrawal syndrome, including with prolonged use [230].
For patients with GAD, to relieve anxiety symptoms in case of refractory response to other types of pharmacotherapy, it is recommended to use #etifoxine (ATX code: N05BX03) (150-200 mg/day) [120-122].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Comment: The drug has not been specifically studied in GAD, has not been investigated in RCTs, and appears to be less effective for treating anxiety symptoms than other drugs; however, extensive positive experience has been accumulated with its symptomatic use as an anxiolytic in domestic psychiatric practice. In addition, when assessing the risk/benefit ratio compared to benzodiazepine derivatives, it has a number of advantages, in particular, the absence of the risk of dependence formation and the possibility of long-term prescription. This should be especially kept in mind when comorbid psychoactive substance dependence is suspected; in a clinical interview, these patients often tend to minimize or conceal their addictive history from the physician.
In patients with GAD receiving psychotropic medications, it is recommended to regularly evaluate the following potential adverse effects of psychopharmacotherapy: sedation, somnolence, lethargy, urinary retention, constipation or diarrhea, nausea, headaches, dizziness, coordination impairment, concentration impairment, memory impairment, formation of dependence and drug tolerance, sexual dysfunctions, etc. It is necessary to evaluate the adverse effects of specifically prescribed drugs in order to assess the efficacy/tolerability ratio [33,34,35,36,42,45,47,55,61,83,178].
Level CLevel 3Level of recommendation evidence C (reliability level of evidence – 3).
Comment: Adequate dosages and administration regimens strictly according to indications significantly reduce the risk of adverse effects. Recommended drug doses for the treatment of GAD are presented in Appendix A3.
In patients with GAD receiving psychopharmacological medications, it is recommended to assess the efficacy and tolerability of therapy, which is carried out on days 7, 14, and 28 of psychopharmacotherapy and subsequently every 4 weeks until the end of the treatment course for its timely adjustment [33,34,35,45,47,49,84].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Comment: Dynamic assessment of treatment efficacy in patients with GAD can be performed using the Hamilton Anxiety Rating Scale (HARS) to evaluate the effectiveness of ongoing treatment. Response to therapy is defined as a reduction in the total Hamilton Anxiety Rating Scale score by > 50% and achievement of remission < 7 points (The Hamilton Anxiety Rating Scale, abbr. HARS). In cases of insufficient efficacy of monotherapy after 4-6 weeks, changing the drug or using combination treatment regimens is recommended. The therapeutic algorithm for switching medications is provided in Appendix B3. In case of intolerance or insufficient efficacy, dosage adjustment or a change of medication is performed.
Continuation and long-term psychopharmacotherapy
GAD is a chronic psychiatric disorder characterized by periodic exacerbations of anxiety symptoms, which requires the physician to continuously monitor the patient's condition. In order to maintain the achieved therapeutic effect and prevent relapses, continuation and maintenance (relapse-prevention) psychopharmacotherapy is carried out. Such therapy should be as sparing as possible in terms of patient tolerability, but sufficiently effective. To evaluate these parameters and adherence, monthly monitoring of the patient's condition is performed.
For all patients with GAD at the initial stage, it is recommended to carry out effective therapy for at least 6 months after the onset of the therapeutic effect in order to stabilize it and prevent relapses [2,3,10,33,34,35,36,39,40,41,42,43,44,45].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Comment: In most cases, a longer treatment period – 12 months or more is advisable, since GAD has a high risk of relapse. To prevent relapses once stabilization is achieved with antidepressants, it is advisable to continue their use at the same dosage at which the therapeutic effect was achieved for another 6–12 months.
For all patients upon planned completion of long-term antidepressant therapy or forced premature discontinuation (due to poor compliance or tolerability), a gradual dose reduction is recommended to prevent withdrawal symptoms [179,180,181].
GCR BLEL 2Level of Evidence - B (level of data reliability – 2).
Comment: The dose reduction period can take several days, weeks, or even months, depending on the dose, duration of treatment, pharmacological properties of the drug, and specific characteristics of the patient's condition. The need for a gradual dose reduction is due to the possibility of developing antidepressant withdrawal syndrome (AWS) [182,183]. These are usually transient and rapidly resolve upon re-administration of the antidepressant. The risk of their development is higher the more pronounced the anticholinergic properties of the drug, the higher the dose used, and the longer the period of administration. Among new-generation antidepressants, AWS is most characteristic of #venlafaxine [227] and short-acting SSRIs (e.g., paroxetine**), and less characteristic of #fluoxetine**. Abrupt withdrawal of TCAs can cause a cholinergic "rebound" phenomenon (flu-like state, myalgia, cramping abdominal pain). To avoid AWS or correct its manifestations in case of a decision to discontinue the antidepressant, the following algorithm for the prevention and management of patients with antidepressant withdrawal syndrome is proposed (see Appendix B4).
The duration of maintenance therapy for GAD is determined based on the patient's individual characteristics, the dynamics of the clinical picture, and concomitant treatment. [33,34,36,38,40,41]. Patients receiving long-term therapy need regular medical follow-up to detect early signs of relapse and timely relieve them, monitor potential side effects of therapy and adherence to the drug regimen, conduct psychotherapeutic measures aimed at motivating the patient to continue treatment, and provide assistance in the event of psycho-traumatic situations.
3.3 Psychotherapy
Psychotherapy is a proven effective method for treating neurotic disorders, including generalized anxiety disorder. The combination of psychopharmacotherapy and psychotherapy is optimal, as it best corresponds to the modern biopsychosocial concept of the formation of mental disorders and makes it possible to implement the principles of personalized medicine and increase the effectiveness of therapeutic interventions. There are evidence-based studies regarding a number of psychotherapeutic methods. However, it must be remembered that the design of evidence-based studies in psychotherapy is quite complex and clinical practice differs in many respects from a scientific experiment. The large number of sources showing the effectiveness of cognitive behavioral therapy is associated rather with the ability within scientific research to reproduce certain techniques, and not with the unconditional priority of this method for patients with generalized anxiety disorder. Other psychotherapeutic methods that currently have a smaller evidence base may be no less, and perhaps in certain cases more, effective than cognitive behavioral therapy. [2,37,38, 85,86,87,88,89,90,91]. There is evidence of the effectiveness of integrating several psychotherapeutic methods [184].
Contraindications and limitations to psychotherapeutic treatment [2,37,38]:
1) patients with a fear of self-disclosure and the predominance of denial in the complex of psychological defense mechanisms used;
2) patients with insufficient motivation for change, obvious secondary gain from the illness;
3) patients with low interpersonal sensitivity;
4) patients who are unable to attend psychotherapy sessions regularly;
5) patients who will not participate in the process of active verbalization and listening in individual and group psychotherapy;
6) patients whose characterological features do not allow them to work constructively in individual and group psychotherapy and 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 all patients with GAD, it is recommended to use various psychotherapy methods in combination with psychopharmacotherapy for a more effective and sustained reduction of anxiety, relaxation training, correction of irrational beliefs, increase of tolerance to uncertainty and vegetative-somatic manifestations of anxiety, attitudes, correction of dyssomnia (sleep normalization), and awareness of deep mechanisms and contradictions. Isolated use of psychotherapy is possible in cases of mildly expressed symptoms [2,37,38, 85,86,87,88,89,90,91,231].
GGR BLOC 1Grade of Recommendation B (Level of Evidence – 1).
For all patients with GAD, the use of relaxation psychotherapy methods for 10-15 sessions is recommended in order to reduce anxiety and tension, teach self-regulation skills, and reduce tension levels [2,37,85,88,89,233].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
For all patients with GAD, except for patients with intellectual disability, cognitive behavioral psychotherapy is recommended in order to reduce anxiety and tension, change irrational attitudes, and master adaptive thinking and behavior skills [2,38,87,88,89,90,91,92,93].
GPP ALOE 1Grade of Recommendation A (Level of Evidence – 1).
Comment: Cognitive model of generalized anxiety disorder. The thinking of an anxious patient is dominated by themes of danger, i.e., they anticipate events that will prove detrimental to themselves, their family, their property, and other values. Anxious individuals experience difficulties in recognizing safety signals and other evidence that reduces the threat of danger.
The targets of cognitive behavioral therapy for GAD are: low tolerance to uncertainty; positive beliefs regarding worry; lack of problem-solving orientation; cognitive avoidance.
The following techniques within cognitive behavioral psychotherapy can be used to treat GAD.
Cognitive restructuring. Interventions are carried out to correct erroneous notions and interpretations of bodily sensations. It can be supplemented by in vivo exposure to obtain additional information that will disprove erroneous judgments.
Breathing retraining. Indicated in cases of a prominent hyperventilation component in the structure of anxiety. The training can be supplemented by forced hyperventilation with the acquisition of skills to control symptoms by breathing into a paper bag.
Applied relaxation. Use of progressive muscle relaxation and training patients in physical state self-regulation skills.
Worry awareness training (with logs of the time and content of worrying thoughts)
Training aimed at recognizing and overcoming one's own low tolerance to uncertainty.
Training aimed at developing problem-solving behavior skills
Other cognitive behavioral therapy techniques may also be used [2,3,85,91,93].
Individual cognitive behavioral therapy for GAD can be supplemented by a group format.
In the cognitive behavioral approach, metacognitive therapy is most frequently used for the treatment of GAD. There are also studies demonstrating the efficacy of other third-wave CBT methods: acceptance and commitment therapy (ACT), mindfulness-based cognitive therapy (MBCT), and mindfulness-based stress reduction (MBSR) techniques [185,186,187,188,189,190,191].
CBT has proven its efficacy for the treatment of GAD in both individual and group formats [192,193,194]. The goal of this method is to reduce cognitive and behavioral avoidance of uncertain situations or cognitions that cause worry in GAD patients. Therapy includes self-monitoring, assessment of positive beliefs about worry and avoidant behavior, exposure training, and improvement of problem orientation. Patients learn to divide their concerns regarding uncertain situations into two categories: real problems that are part of life (e.g., meeting deadlines for work tasks) and hypothetical situations (e.g., a potential accident). In the former case, training aimed at developing problem-solving skills is conducted; in the latter, imaginal exposure is performed [195].
The development of technical capabilities has contributed to the creation of methodologies utilizing virtual reality, software for personal computers, smartphones, and other digital tools [196,197,198]. Research data indicate the efficacy of cognitive behavioral psychotherapy using internet and telecommunication technologies (e.g., internet-delivered CBT) [199,200]. The remote use of CBT increases the availability of psychotherapeutic care for patients living in remote areas with poor transport accessibility, as well as in cases where qualified specialists are absent locally. In the absence of the possibility of remote work with a specialist in real time, low-intensity remote CBT has demonstrated efficacy [201]. During treatment, patients independently and systematically complete pre-prepared structured lessons or modules containing the same information usually provided in face-to-face sessions. Although low-intensity CBT has demonstrated efficacy, this option of psychotherapy is associated with a risk of reduced patient motivation and treatment adherence [202]. For elderly individuals who lack internet access and digital technology skills, telephone-delivered cognitive behavioral psychotherapy has proven its efficacy in randomized controlled trials [203,204].
For patients with GAD in whom an intrapsychic conflict is identified during history taking, dynamic personality-oriented (reconstructive) psychotherapy (individual and/or group) is recommended in order to reduce anxiety and tension, raise awareness of the deep mechanisms of the disease, resolve internal contradictions, and reconstruct the system of relations [2,85,94,95,234].
Level of Evidence BLevel of Confidence 2Level of recommendation B (level of evidence – 2).
Comment: Psychotherapy aims to restore the patient's disturbed system of relations through studying the specifics of their personality disorders, analyzing and raising awareness of the features of the patient's system of relations, the pathogenic situation, and the neurotic conflict. The balanced use of therapeutic mechanisms (confrontation, emotionally corrective experience, and learning) allows modifying the patient's disturbed relations, taking into account three planes of expected changes (in the cognitive, emotional, and motivational-behavioral spheres), with individual psychotherapy, unlike group psychotherapy, focusing to a greater extent on cognitive aspects [2,85].
For patients with GAD who have specific parental representations, psychotraumatic situations, and difficulties in expressing and regulating feelings of anger and rage, short-term psychodynamic psychotherapy (STPP) is recommended to foster awareness of the deep mechanisms of the disease, resolve internal contradictions, and reduce anxiety levels [205,206,207].
LoR ALE 1Level of Recommendation A (Level of Evidence – 1).
Comment: STPP is a form of psychodynamic psychotherapy whose mechanisms include facilitating the therapeutic alliance, developing emotional capacities, increasing self-awareness, and providing an emotionally corrective experience. During psychotherapy, intrapsychic neurotic conflicts and patterns of interpersonal maladaptive behavior are identified. The therapeutic alliance is used as a means of therapeutic intervention. There is evidence regarding the effective remote use of STPP [208].
For patients with GAD and insomnia, a comprehensive medical and psychological treatment method for patients with insomnia is recommended in order to normalize sleep [209].
GRC BLEL 2Grade of Recommendation B (Level of Evidence – 2)
Comment: According to studies, insomnia disorders occur in 18–40% of patients with generalized anxiety disorder (GAD), representing a risk factor for a more severe course of GAD and the development of comorbid affective disorders [210, 211].
An open-label randomized prospective controlled parallel-group study with blinded rater assessment was conducted in accordance with the clinical probation protocol "Complex Medical and Psychological Methodology for Insomnia Treatment" (protocol index: 2020-37-3). The results of the quantitative evaluation of the clinical probation method's efficacy were assessed using seven indicators: improvement of subjective sleep characteristics; improvement of sleep quality; reduction of the insomnia severity index; reduction of daytime sleepiness; reduction of the consequences of sleep disturbances; reduction of anxiety severity; and improvement of the Clinical Global Impression. The target outcome was achieved across all parameters, ranging from 87% to 100%. Although no isolated sample of GAD patients was specifically separated, a significant reduction in anxiety and normalization of sleep allow this methodology to be used in patients with anxiety disorders presenting with sleep disturbances, including GAD.
The complex medical and psychological insomnia treatment program includes 10 individual cognitive behavioral psychotherapy sessions (frequency: twice a week, duration: 60 minutes) and 10 sessions of complex psychophysiological methods (frequency: 3 times a week, duration: 60 minutes), which include diaphragmatic breathing training (45 minutes) and light therapy (15 minutes). The total number of sessions is 20. The program duration is 5 weeks. During individual cognitive behavioral psychotherapy, the patient learns the basic principles of sleep hygiene, techniques aimed at independently identifying and relieving neuropsychic tension, and skills for identifying and challenging dysfunctional beliefs regarding sleep, the causes of insomnia, and methods for its correction, which overall contributes to the formation of a rational thinking system. The course of psychotherapy combined with light therapy and diaphragmatic breathing is aimed at teaching the patient self-analysis and self-regulation, which makes it possible to independently monitor and regulate one's condition, recognize the initial manifestations of pathological states, independently prevent or stop them, and seek qualified medical help in a timely manner if necessary.
3.4 Other treatment methods
In patients with GAD refractory to psychopharmacotherapy and psychotherapy, the use of transcranial magnetic stimulation (TMS) (medical service code: A17.23.004.001) is recommended to enhance the therapeutic effect and additionally target anxiety and comorbid depressive symptoms [212, 213].
GCR BLOE 2Grade of Recommendation B (Level of Evidence – 2).
Comment: The highest efficacy is observed in anxiety disorders with comorbid depressive symptoms, where the same stimulation protocols are used as for the treatment of depression. It is believed that anxiety is more closely associated with the activity of the right hemisphere, including the simultaneous activation of the right ventrolateral prefrontal cortex and the right amygdala; therefore, low-frequency TMS of the right DLPFC is frequently used for its correction [212]. However, an anxiolytic effect was also noted with high-frequency (20 Hz) TMS of the left DLPFC, presumably due to the stimulation of fronto-subcortical neural networks [213]. The course of therapy consists of 15 TMS procedures over 3 weeks. Unlike psychopharmacotherapy, TMS is well tolerated and has virtually no side effects.
In patients with GAD showing insufficient response to psychopharmacotherapy and psychotherapy, or presenting with autonomic instability or autonomic regulation disorders, the use of biofeedback therapy (medical service code A19.23.003.008: biofeedback training for central nervous system disorders) is recommended — 10 sessions aimed at reducing anxiety and tension, teaching self-regulation skills, and lowering tension levels [36, 85, 123, 214, 215, 216, 217].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
4. Medical Rehabilitation and Sanatorium-Resort Treatment
All patients with GAD are recommended to undergo rehabilitation measures aimed at shortening the period of temporary disability, early socialization in society, and improving quality of life [1, 2, 34, 36, 85].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
In all patients with GAD, the use of sociocentric and psychocentric supportive psychotherapeutic methods is recommended with the aim of shortening the period of temporary disability, promoting early socialization, and improving quality of life [1, 2, 34, 36, 85].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
In all patients with GAD, family, socio-psychological, and professional supportive psychotherapy and/or psychological correction are recommended as special types of rehabilitation to improve the quality and efficacy of treatment [1, 2, 34, 36, 85, 218].
In all patients with GAD, as one of the important forms of rehabilitation measures, supportive psychotherapy is recommended to improve the quality and efficacy of treatment, which can be delivered on an outpatient basis as individual or group psychotherapy [1, 2, 34, 36, 85, 219, 220].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
5. Prevention and Dispensary Observation
There is no specific prevention for GAD. Prevention of GAD consists in implementing healthy lifestyle principles, measures aimed at maintaining public mental health, and limiting alcohol and psychoactive substance use. It also includes informing the public about the signs of GAD for early detection and timely medical consultation.
All patients with GAD are recommended to adhere to healthy lifestyle principles and implement measures aimed at maintaining public mental health for the prevention of anxiety disorders [1, 2, 34, 36, 36, 85, 96, 97, 137].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
All patients with GAD are recommended to be monitored and managed by a psychotherapist or psychiatrist for therapy adjustment, safe discontinuation, and psychotherapy delivery [1, 2, 34, 36, 85, 147, 232].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
All patients with GAD are recommended to undergo dispensary observation (active clinical monitoring) by a psychiatrist in cases of suicide risk, severe disease course, comorbid mental pathology, or treatment resistance, with the aim of dynamically assessing the condition, determining indications for outpatient treatment adjustment, and ensuring timely hospital admission [1, 2, 34, 36, 85, 147, 232].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Patients with GAD who are underweight or overweight are recommended medical nutrition therapy to improve their psycho-emotional status and correct emotional dysregulation [221].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Dispensary observation (active clinical monitoring) may be established regardless of the consent of the individual suffering from a mental disorder or their legal representative in cases provided for by Part 1, Article 27 of the Law of the Russian Federation dated July 2, 1992, No. 3185-1 "On Psychiatric Care and Guarantees of Citizens' Rights in Its Provision" (hereinafter referred to as Law No. 3185-1).
"Decisions on the necessity of establishing dispensary observation and its termination are made by a commission of psychiatrists appointed by the head of a medical organization providing outpatient psychiatric care, or by a commission of psychiatrists appointed by the executive authority of a constituent entity of the Russian Federation in the field of healthcare" (Part 2, Article 27 of Law No. 3185-1). Such an examination is possible both upon the individual's voluntary request for psychiatric care and involuntarily, if there are indications for an involuntary examination.
The grounds for establishing dispensary observation are the presence of a chronic and protracted mental disorder with severe, persistent, or frequently exacerbating pathological manifestations (Part 1, Article 27 of Law No. 3185-1).
The procedure for dispensary observation of an individual suffering from a chronic and protracted mental disorder with severe, persistent, or frequently exacerbating pathological manifestations is determined by Order of the Ministry of Health of the Russian Federation dated June 30, 2022, No. 453n "On Approval of the Procedure for Dispensary Observation of an Individual Suffering from a Chronic and Protracted Mental Disorder with Severe, Persistent, or Frequently Exacerbating Pathological Manifestations," which entered into force on March 1, 2023.
In accordance with the appendix to the Procedure, 5 dispensary observation groups have been defined: D-1, D-2, D-3, D-4, and D-5 (active dispensary observation), within which subgroups may be distinguished if necessary.
Upon recovery or significant and persistent improvement in an individual's mental state, dispensary observation is terminated (Part 4, Article 27 of Law No. 3185-1).
Dispensary observation group | Chronic and protracted mental disorder with severe, persistent, or frequently exacerbating pathological manifestations, the presence of which warrants the establishment of the dispensary observation group | Minimum frequency of dispensary visits (examinations, consultations) | Controlled health status indicators within the framework of dispensary observation | Notes |
|---|---|---|---|---|
D-1 | A chronic and protracted mental disorder with severe, persistent, or frequently relapsing clinical manifestations (hereinafter referred to as the mental disorder), which required hospitalization in a medical organization providing inpatient psychiatric care (hereinafter referred to as the medical organization) 1 time per year or more frequently and/or lasting for more than 120 days within a 2-year period | At least 1 time per month | Presence (absence) of suicidal thoughts and intentions or self-harming behavior — at each dispensary appointment (examination, consultation) by a psychiatrist; symptoms predisposing to socially dangerous acts — at each dispensary appointment (examination, consultation) by a psychiatrist; weight (body mass index), waist circumference — 1 time in 3 months; blood pressure — 1 time per month; complete blood count — at least 1 time per year; blood prolactin level (when prescribing antipsychotic medications) — at least 1 time per year; electrocardiogram — at least 1 time per year | The following subgroups are determined within the dispensary observation group, if necessary: N — individuals at the initial stages of a mental disorder; C — individuals with suicidal thoughts and intentions; Z — individuals with mental and behavioral disorders who have comorbid conditions associated with psychoactive substance use; K — individuals with low treatment adherence; P — individuals receiving treatment with long-acting injectable medications |
D-2 | A mental disorder that required hospitalization in a medical organization 1 time every 2 years and lasted for less than 120 days within a 2-year period | During the first year — at least 1 time per month; thereafter — at least 1 time every 2 months | Presence (absence) of suicidal thoughts and intentions or self-harming behavior — at each dispensary appointment (examination, consultation) by a psychiatrist; symptoms predisposing to socially dangerous acts — at each dispensary appointment (examination, consultation) by a psychiatrist; weight (body mass index), waist circumference — 1 time in 3 months; blood pressure — 1 time every 2 months; complete blood count — at least 1 time per year; blood prolactin level (when prescribing antipsychotic medications) — at least 1 time per year; electrocardiogram — at least 1 time per year | |
D-3 | A mental disorder that did not require hospitalization in a medical organization for 3 years or more | At least 1 time in 3 months | Presence (absence) of suicidal thoughts and intentions or self-harming behavior — at each dispensary appointment (examination, consultation) by a psychiatrist; symptoms predisposing to socially dangerous acts — at each dispensary appointment (examination, consultation) by a psychiatrist; weight (body mass index), waist circumference — 1 time in 3 months; blood pressure — 1 time in 3 months; complete blood count — at least 1 time per year; blood prolactin level (when prescribing antipsychotic medications) — at least 1 time per year; electrocardiogram — at least 1 time per year | |
D-4 | A mental disorder in remission or compensation, which did not require hospitalization in a medical organization for 5 years or more | At least once a year | Presence (absence) of suicidal thoughts and intentions or self-harming behavior — at each dispensary appointment (examination, consultation) by a psychiatrist; symptoms predisposing to socially dangerous acts — at each dispensary appointment (examination, consultation) by a psychiatrist; weight (body mass index), waist circumference — at least 1 time per year; blood pressure — at each dispensary appointment (examination, consultation) by a psychiatrist; complete blood count — at least 1 time per year; blood prolactin level (when prescribing antipsychotic medications) — at least 1 time per year; electrocardiogram — at least 1 time per year | |
D-5 (active dispensary observation) | A mental disorder upon establishment of the following facts: 1) commission of socially dangerous acts by the individual (including according to medical history); 2) court-ordered outpatient compulsory observation and treatment by a psychiatrist; 3) court-ordered other types of compulsory medical measures (including according to medical history); 4) a court decision to terminate the application of compulsory medical measures in a medical organization; 5) presence in the individual's mental disorder structure of symptoms predisposing to socially dangerous acts (imperative hallucinations, certain forms of delusions, psychopathy-like states with increased behavioral activity and drive pathology, etc.) (including according to medical history) | Within 10 working days after the establishment of dispensary observation; thereafter at least 1 time per month | Presence (absence) of suicidal thoughts and intentions or self-harming behavior — at each dispensary appointment (examination, consultation) by a psychiatrist; symptoms predisposing to socially dangerous acts — at each dispensary appointment (examination, consultation) by a psychiatrist; pathopsychological examination — at least 1 time per year; weight (body mass index), waist circumference — 1 time in 3 months; blood pressure — 1 time per month; complete blood count — at least 1 time per year; blood prolactin level (when prescribing antipsychotic medications) — at least 1 time per year; presence and/or concentration of medicinal products and their metabolites in biological samples (urine and/or blood) as part of monitoring the treatment prescribed by a psychiatrist — at least 1 time in 6 months; electrocardiogram — at least 1 time per year |
6. Organization of Medical Care
Indications for hospitalization in a medical organization [147,232]:
Severe anxiety requiring selection of pharmacotherapy in an inpatient setting;
Presence of comorbid mental disorders requiring selection of drug therapy in an inpatient setting;
Presence of comorbid somatic disorders requiring selection of drug therapy in an inpatient setting;
Pronounced phobic states with restrictive behavior;
Poor tolerability of drug therapy;
Systematic alcohol use to reduce anxiety severity.
Indications for discharge of the patient from a medical organization [147,232]:
Selection of adequate and effective pharmacotherapy;
Absence of pronounced adverse events;
Reduction in anxiety levels;
Stabilization of the mental state;
Stabilization of the somatic state;
Abatement of phobic states with overcoming restrictive behavior.
7. Additional Information
Factors contributing to a protracted course (predictors of a protracted course of generalized anxiety disorder) [2,35,85,96,97]
Criteria for Evaluating the Quality of Medical Care
Quality assessment criteria for primary health care provided to adults with generalized anxiety disorder (ICD-10 codes: F41.1)
№ | Quality criterion | Score performed |
|---|---|---|
1 | Initial examination (assessment, consultation) by a psychiatrist/psychotherapist with a comprehensive clinical and psychopathological evaluation (including medical history taking, suicide risk assessment, severity of panic attacks and avoidant behavior) | Yes/No |
2 | Experimental psychological (psychodiagnostic) testing performed (upon establishing the diagnosis). | Yes/No |
3 | Individual clinical and psychological counseling performed | Yes/No |
4 | Prescription of antidepressants and/or anxiolytics (as abortive, maintenance, or prophylactic therapy, depending on medical indications and in the absence of contraindications) | Yes/No |
5 | Change of therapy in case of ineffectiveness or intolerance | Yes/No |
6 | Individual and/or group psychotherapy and social rehabilitation | Yes/No |
7 | Follow-up examination (assessment, consultation) by a psychiatrist/psychotherapist to evaluate treatment efficacy | Yes/No |
Quality assessment criteria for specialized medical care in adults with GAD (ICD-10 code F41.1)
№ | Quality criterion | Score performed |
|---|---|---|
1 | Daily examination by a psychiatrist/psychotherapist with monitoring and care by nursing staff in an inpatient unit, including evaluation of therapy efficacy | Yes/No |
2 | Experimental psychological (psychodiagnostic) testing performed (upon establishing the diagnosis). | Yes/No |
3 | Individual clinical and psychological counseling performed | Yes/No |
4 | Electrocardiogram recording performed | Yes/No |
5 | Treatment with antidepressants and/or anxiolytics (depending on medical indications and in the absence of contraindications) | Yes/No |
6 | Individual and/or group psychotherapy, social rehabilitation | Yes/No |
7 | Change of therapy in case of ineffectiveness or intolerance | Yes/No |
8 | Assessment of efficacy and safety of continuing relapse-prevention outpatient therapy. | Yes/No |
References
Show references
Tyrer P. Generalised anxiety disorder / P. Tyrer, D. Baldwin // Lancet. - 2006. - Vol. 16, №368(9553). - Р. 2156-2166. - DOI: 10.1016/S0140-6736(06)69865-6
Karavaeva T.A. Kholisticheskaya diagnostika pogranichnykh psikhicheskikh rasstroistv / T. A. Karavaeva, A. P. Kotsyubinsky. - Saint Petersburg: Spetslit, 2017. - 286 p.
Zalutskaya N.M. Generalized anxiety disorder: current theoretical models and approaches to diagnosis and therapy. Part 1 / N. M. Zalutskaya // V.M. Bekhterev Review of Psychiatry and Medical Psychology. - 2014. - № 3. - P. 80-89.
Zalutskaya N.M. Generalized anxiety disorder: current theoretical models and approaches to diagnosis and therapy. Part 2 / N. M. Zalutskaya // V.M. Bekhterev Review of Psychiatry and Medical Psychology. - 2014. - № 4. - P. 129-134.
Maron E. Biological markers of generalized anxiety disorder / E. Maron, D. Nutt / Dialogues Clin. Neurosci. - 2017. - Vol. 19(2) - P. 147-158. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5573559
Eng W. Interpersonal correlates of generalized anxiety disorder: self versus other perception / W.Eng, R. G. Heimberg // Anxiety Disorders. - 2006. - Vol.20. -P.380-387. - DOI: 10.1016/j.janxdis.2005.02.005
Bobrov A.E. Klinicheskie, lichnostnye i kognitivno-stilevye osobennosti bolnykh s trevozhnymi rasstroistvami / A. E. Bobrov, E. V. Faizrakhmanova // Russian Journal of Psychiatry. - 2017. - № 5. - P. 50-58.
Bandelow B. Epidemiology of anxiety disorders in the 21st century / B. Bandelow, S. Michaelis // Dialogues Clin. Neurosci. - 2015. - Vol. 17(3). - P. 327-335. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4610617
Kessler R.C. The epidemiology of generalized anxiety disorder / R. C.Kessler, M. B. Keller, H. U. Wittchen // Psychiatr. Clin. North Am. - 2001. - Vol. 24. - P. 19-39.
Lijster J.M. The Age of Onset of Anxiety Disorders / J. M. Lijster, B. Dierckx, E. M. Utens et al. // Can. J. Psychiatry. - 2017 Vol. 62(4). - P. 237-246. - doi: 10.1177/0706743716640757.
Weisberg Risa B. Overview of generalized anxiety disorder: epidemiology, presentation, and course / Risa B. Weisberg // J.Clin. Psychiatry. - 2009. - Vol. 70, Suppl. 2. - P. 4-9.
Stein D.J. Epidemiology of anxiety disorders: from surveys to nosology and back / D. J. Stein, K. M. Scott, P. de Jonge, R. C. Kessler // Dialogues Clin. Neurosci. - 2017 / - Vol. 19(2). - P. 127-136.
Martynykhin I.A. Gendernye razlichiya epidemiologii i patogeneza depressivnykh i trevozhnykh rasstroistv v kontekste ikh vliyaniya na effektivnost terapii sertralinom (Zoloftom) / I. A. Martynykhin // P.B. Gannushkin Psychiatry and Psychopharmacotherapy. - 2019. - № 03. - P. 52-58.
Zalutskaya N.M. Generalized anxiety disorder: from formation mechanisms to rational therapy / N. M. Zalutskaya // V.M. Bekhterev Review of Psychiatry and Medical Psychology. - 2013. - № 3. - P. 99-111.
Veltishchev D.Yu. Diagnostics and treatment of generalized anxiety disorder (literature review) / D. Yu. Veltishchev // Modern Therapy of Mental Disorders. - 2018. - № 3. - P. 26-37.
Romasenko L.V. Generalized anxiety disorder in general medical practice: clinical presentation and treatment / L. V. Romasenko, Yu. A. Alexandrovsky, V. M. Makhov et al. // Psychiatry and Psychopharmacotherapy: P.B. Gannushkin Journal. - 2015. - № 3 - P. 56-59.
Voznesenskaya T.G. Generalized anxiety disorder: differential diagnosis and treatment / T. G. Voznesenskaya // Neurology, Neuropsychiatry, Psychosomatics. - 2013. - № 2. - P. 18-22.
Almagambetova A.A. Klinicheskie osobennosti i terapiya generalizovannogo trevozhnogo rasstroistva / A. A. Almagambetova, Sh. B. Toleubaeva, S. K. Sataeva, E. A. Pavlyukova // Science and Healthcare. - 2013. - № 4. - P. 71-74.
Veltishchev D.Yu. Generalized anxiety disorder: challenges in diagnosis, prognosis, and psychopharmacotherapy / D. Yu. Veltishchev, A. S. Marchenko // Modern Therapy of Mental Disorders. - 2013. - № 1. - P. 17-23.
Volel B.A. Cognitive impairments in anxiety disorders / B. A. Volel, D. S. Petelin, R. V. Akhapkin, A. A. Malyutina // Neurology, Neuropsychiatry, Psychosomatics. - 2018. - Vol. 10, № 1. - P. 78-82.
Hoehn-Saric R. Somatic symptoms and physiologic responses in generalized anxiety disorder and panic disorder: An ambulatory monitor study / R. Hoehn-Saric, D. R. McLeod, F. Funderburk, P. Kowalski // Archives of General Psychiatry. - 2004. - Vol. 61(9). - P. 913-921. - DOI: 10.1001/archpsyc.61.9.913
Karavaeva T.A. Kriterii i algoritm diagnostiki generalizovannogo trevozhnogo rasstroistva / T. A. Karavaeva, A. V. Vasilyeva, S. V. Poltorak et al. // V.M. Bekhterev Review of Psychiatry and Medical Psychology. - 2015. - № 3. - P. 124-130.
Bruce S.E. Influence of psychiatric comorbidity on recovery and recurrence in generalized anxiety disorder, social phobia and panic disorder: 12-year prospective study / S. E. Bruce, K. A. Yonkers, M. W. Otto // Am. J. Psychiatry. - 2005. - Vol. 162(6). - P. 1179-1187. - DOI: 10.1176/appi.ajp.162.6.1179
Pavlova B. Prevalence of current anxiety disorders in people with bipolar disorder during euthymia: a meta-analysis / B. Pavlova, R. H. Perlis, O. Mantere et al. // Psychol. Med. - 2017. - Vol. 47(6). - P. 1107-1115. - doi: 10.1017/S0033291716003135.
Preti A. Prevalence, impact and treatment of generalised anxiety disorder in bipolar disorder: a systematic review and meta-analysis / A. Preti, J. Vrublevska, A. A. Veroniki et al. // Evid. Based Ment. Health. - 2016. - Vol. 19(3). - P. 73-81. - doi: 10.1136/eb-2016-102412.
YapiciEser H. Prevalence and Associated Features of Anxiety Disorder Comorbidity in Bipolar Disorder: A Meta-Analysis and Meta-Regression Study [Electronic resource] / H. YapiciEser, A. S. Kacar, C. M. Kilciksiz et al. // Front Psychiatry. - 2018. - Vol. 27:9:229. - doi: 10.3389/fpsyt.2018.00229. - Access mode: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6030835/
Mosolov S.N. Trevozhnye i depressivnye rasstroistva: komorbidnost i terapiya / S. N. Mosolov. - M.: Antinfo, 2007. - 32 p.
Salmina-Khvostova O.I. Tiapride in the treatment of generalized anxiety disorder comorbid with alcoholism / O. I. Salmina-Khvostova, D. V. Zyablitsev // Russian Journal of Psychiatry. - 2014. - № 4. - P. 53-57.
Shavlovskaya O.A. Management of anxiety disorders: focus on the comorbid patient / O. A. Shavlovskaya, S. L. Kuznetsov // Therapeutic Archive. - 2018. - № 4. - P. 67-71
Levin O.S. Generalized anxiety disorder: diagnosis, comorbidity, and treatment / O. S. Levin // Modern Therapy in Psychiatry and Neurology. - 2016. - № 2. - P. 4-10.
Neznanov N.G. Features of diagnosing generalized anxiety disorder by Russian psychiatrists: results of a study using brief clinical descriptions / N. G. Neznanov, I. A. Martynykhin // Modern Therapy of Mental Disorders. - 2018. - № 4. - P. 51-59.
Alexandrovsky Yu.A. Ratsionalnaya farmakoterapiya v psikhiatricheskoy praktike [Electronic resource]: a guide for practicing physicians / ed. by Yu. A. Alexandrovsky, N. G. Neznanov - M.: Litterra, 2014. - 1080 p. (Rational Pharmacotherapy Series) - ISBN 978-5-4235-0134-1 - Access mode: https://www.rosmedlib.ru/book/ISBN9785423501341.html.
Mosolov S.N. Algorithm for biological therapy of generalized anxiety disorder / S. N. Mosolov, P. V. Alfimov // Modern Therapy of Mental Disorders. - 2015. - № 2. - P. 24-28.
Bandelow B, Allgulander C, Baldwin DS, Costa DLDC, Denys D, Dilbaz N, Domschke K, Eriksson E, Fineberg NA, Hattenschwiler J, Hollander E, Kaiya H, Karavaeva T, Kasper S, Katzman M, Kim YK, Inoue T, Lim L, Masdrakis V, Menchon JM, Miguel EC, Moller HJ, Nardi AE, Pallanti S, Perna G, Rujescu D, Starcevic V, Stein DJ, Tsai SJ, Van Ameringen M, Vasileva A, Wang Z, Zohar J. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for treatment of anxiety, obsessive-compulsive and posttraumatic stress disorders - Version 3. Part I: Anxiety disorders. World J Biol Psychiatry. 2023 Feb;24(2):79-117. doi: 10.1080/15622975.2022.2086295. Epub 2022 Jul 28. PMID: 35900161
Kostyukova E.G. Differentiated pharmacotherapy of generalized anxiety disorder / E. G. Kostyukova, M. Ya. Ladyzhensky // Modern Therapy of Mental Disorders. - 2018. - № 1. - P. 45-52.
Karavaeva T. A., Vasilyeva A. V., Poltorak S. V., Kolesova Yu. P. [Principles and algorithms of psychopharmacological treatment of neurotic-level anxiety disorders (anxiety-phobic, panic, and generalized anxiety disorders)]. Obozrenie psikhiatrii i meditsinskoy psikhologii im. V.M. Bekhtereva. 2016; (1): 3-9. (In Russ.)
Bandelow B., Seidler-Brandler U., Becker A., et al. Meta-analysis of randomized controlled comparisons of psychopharmacological and psychological treatments for anxiety disorders. World J. Biol. Psychiat. 2007; 8(3): 175-187.
Cuijpers P., Sijbrandij M., Koole S. L., et al. [The efficacy of psychotherapy and pharmacotherapy in the treatment of depressive and anxiety disorders: a meta-analysis of direct comparative studies]. Vsemirnaya psikhiatriya (na russkom yazyke). 2013; 2: 130-141. (World Psychiatry. 2013; 12: 137-148). (In Russ.)
Zalutskaya N. M. [Generalized anxiety disorder: modern theoretical models and approaches to diagnosis and therapy. Part 3]. Obozrenie psikhiatrii i meditsinskoy psikhologii im. V.M. Bekhtereva. 2015; (1): 83-89. (In Russ.)
Pavlichenko A. V. [Evidence-based psychopharmacotherapy of generalized anxiety disorder]. Psikhiatriya i psikhofarmakoterapiya. 2015; 17(1): 61-66. (In Russ.)
Baldwin D., Woods R., Lawson R., Taylor D. Efficacy of drug treatments for generalised anxiety disorder: systematic review and meta-analysis [Electronic resource]. BMJ. 2011; 342. Available from: doi: https://doi.org/10.1136/bmj.d1199
Baldwin D. S., Waldman S., Allgulander C. Evidence-based pharmacotherapy of generalized anxiety disorder. In: Stein D., Lerer B., Stahl S. M., eds. Essential Evidence-Based Psychopharmacology. Cambridge University Press; 2013: 110-127. Ch. 7. DOI: https://doi.org/10.1017/CBO9780511910395.008
Bandelow B., Reitt M., Rover C., et al. Efficacy of treatments for anxiety disorders: a meta-analysis. Int. Clin. Psychopharmacol. 2015; 30(4): 183-192. doi: 10.1097/YIC.0000000000000078
Hidalgo R. B., Tupler L. A., Davidson J. R. An effect-size analysis of pharmacologic treatments for generalized anxiety disorder. J. Psychopharmacol. 2007; 21(8): 864-872. DOI: 10.1177/0269881107076996
Slee A., Nazareth I., Bondaronek P., et al. Pharmacological treatments for generalised anxiety disorder: a systematic review and network meta-analysis. Lancet. 2019; 393(10173): 768-777. doi: 10.1016/S0140-6736(18)31793-8.
Starcevic V. Generalized anxiety disorder: Psychopharmacotherapy update on a common and commonly overlooked condition. Australasian Psychiatry. 2015; 23(4): 338-342. doi: 10.1177/1039856215587233.
Cipriani A. Comparative efficacy and acceptability of 12 new-generation antidepressants: a multiple-treatments meta-analysis / A. Cipriani, T. A. Furukawa, G. Salanti et al. // Lancet. - 2009. - Vol. 28. - № 373 (9665). - P. 746-758. - doi: 10.1016/S0140- 6736(09)60046-5.
Davidson J. R. T., Wittchen H.-U., Llorca P.-M., Erickson J. Duloxetine treatment for relapse prevention in adults with generalized anxiety disorder: a double-blind placebo-controlled trial. Eur. Neuropsychopharmacol. 2008; 18(9): 673-681. https://doi.org/10.1016/j.euroneuro.2008.05.002
De Vries Y. A., de Jonge P., van den Heuvel E., et al. Influence of baseline severity on antidepressant efficacy for anxiety disorders: meta-analysis and meta-regression. Br. J. Psychiatry. 2016; 208(6): 515-521. doi: 10.1192/bjp.bp.115.173450
Li X., Zhu L., Su Y., Fang S. Short-term efficacy and tolerability of venlafaxine extended release in adults with generalized anxiety disorder without depression: A meta-analysis [Electronic resource]. PLoS One. 2017; 12(10): e0185865. Available from: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0185865
Rickels K., Zaninelli R., McCafferty J., et al. Paroxetine treatment of generalized anxiety disorder: a double-blind, placebo-controlled study. Am. J. Psychiatry. 2003; 160(4): 749-756. DOI: 10.1176/appi.ajp.160.4.749
Roles S. The largest meta-analysis of pharmaceutical treatments of Generalised Anxiety Disorder consolidates current knowledge and reveals convincing effectiveness of Venlafaxine / S. Roles // Evid.Based Nurs. - 2019. - Vol. 28. - pii: ebnurs-2019-103111. - doi: 10.1136/ebnurs-2019-103111.[Epub ahead of print].
Kostyukova E. G., Mosolov S. N. [Differentiated approach to the use of antidepressants]. Sovremennaya terapiya psikhicheskikh rasstroystv. 2013; (3): 2-10. (In Russ.)
Bech P. Dose-response relationship of pregabalin in patients with generalized anxiety disorder. A pooled analysis of four placebo-controlled trials. Pharmacopsychiatry. 2007; 40(4): 163-168. DOI: 10.1055/s-2007-984400
Generoso M. B., Trevizol A. P., Kasper S., et al. Pregabalin for generalized anxiety disorder: an updated systematic review and meta-analysis. Int. Clin. Psychopharmacol. 2017; 32(1): 49-55.
Lydiard R.Comparative efficacy of pregabalin and benzodiazepines in treating the psychic and somatic symptoms of generalized anxiety disorder / R. B. Lydiard, K. Rickels, B. Herman, D. E. Feltner // Int.J.Neuropsychopharmacol. - 2010. - Vol. 13 (2). - P. 229-241. - DOI: 10.1017/S1461145709990460
RickelsK. Adjunctive therapy with pregabalin in generalized anxiety disorder patients with partial response to SSRI or SNRI treatment / K.Rickels, T. M. Shiovitz, T. S. Ramey et al. // Int. Clin. Psychopharmacol. - 2012. - Vol. 27 (3). - P. 142-150. - DOI: 10.1097/YIC.0b013e328350b133
Montgomery S. A. [Pregabalin in the treatment of generalized anxiety disorder (extended abstract)]. Psikhicheskie rasstroystva v obshchey meditsine. 2010; (1): 55-60. (In Russ.)
Pavlichenko A. V. [Pregabalin in the therapy of generalized anxiety disorder: a critical literature review]. Psikhiatriya i psikhofarmakoterapiya: zhurnal im. P.B. Gannushkina. 2014; (4): 39-45. (In Russ.)
Perna G., Alciati A., Riva A., et al. Long-Term Pharmacological Treatments of Anxiety Disorders: An Updated Systematic Review. Curr. Psychiatry Rep. 2016; 18(3): 23. DOI: 10.1007/s11920-016-0668-3
Avedisova A. S., Yastrebov D. V. [Long-term use of benzodiazepine tranquilizers: prevalence and association with the development of drug dependence]. Psikhiatriya i psikhofarmakoterapiya: zhurnal im. P.B. Gannushkina. 2010; (1): 17-24. (In Russ.)
Neznamov G. G., Metlina M. V., Bogdanova N. I., et al. [Patients' subjective evaluation of anxiolytic effects: dependence on the structure of anxiety disorders]. Psikhiatriya i psikhofarmakoterapiya: zhurnal im. P.B. Gannushkina. 2017; 19(3): 10-18. (In Russ.)
Osadshiy Yu. Yu., Voblenko R. A., Archakov D. S., Tarakanova E. A. [The place of benzodiazepines in the modern therapy of mental disorders (a review of evidence-based studies)]. Sovremennaya terapiya psikhicheskikh rasstroystv. 2016; (1): 2-10. (In Russ.)
Becker R. A., Bykov Yu. V. [Clonazepam: a review of the latest clinical data]. Psikhiatriya i psikhofarmakoterapiya: zhurnal im. P.B. Gannushkina. 2017; (1): 17-29. (In Russ.)
Baldwin D. S., Waldman S. K. Antipsychotic drugs in the treatment of generalized anxiety disorder. Int. J. Psychiat. Clin. Pract. 2009; 13(Suppl.): S10-S10. https://www.ndcn.ox.ac.uk/publications/507094
Hershenberg R., Gros D. F., Brawman-Mintzer O. Role of atypical antipsychotics in the treatment of generalized anxiety disorder. CNS Drugs. 2014; 28(6): 519-533. doi: 10.1007/s40263-014-0162-6.
Maneeton N., Maneeton B., Woottiluk P., et al. Quetiapine monotherapy in acute treatment of generalized anxiety disorder: a systematic review and meta-analysis of randomized controlled trials. Drug Des. Devel. Ther. 2016; 10: 259-276. doi: 10.2147/DDDT.S89485.
Becker R. A., Bykov Yu. V. [Alimemazine: a review of clinical use]. Psikhiatriya i psikhofarmakoterapiya: zhurnal im. P.B. Gannushkina. 2016; (6): 10-20. (In Russ.)
Bykov Yu. V., Becker R. A. [Sulpiride in the therapy of anxiety disorders and anxiety symptoms within other disorders (literature review)]. Psikhiatriya i psikhofarmakoterapiya: zhurnal im. P.B. Gannushkina. 2016; 18(5): 25-33. (In Russ.)
Bykov Yu. V., Becker R. A. [Chlorprothixene: a review of its use in psychiatry (Part I)]. Psikhiatriya i psikhofarmakoterapiya: zhurnal im. P.B. Gannushkina. 2016; (2): 26-32. (In Russ.)
Vorobyova O. V. [Ways to improve the efficacy of therapy for anxiety disorders in neurological practice]. Psikhiatriya i psikhofarmakoterapiya. 2018; (2): 10-15. (In Russ.)
Medvedev V. E. [Alimemazine in psychiatry and psychosomatics]. Psikhiatriya i psikhofarmakoterapiya. 2018; (3-4): 26-33. (In Russ.)
Lader M., Scotto J.-C. [A multicenter double-blind comparative study of hydroxyzine, buspirone, and placebo in patients with generalized anxiety states (extended abstract)]. Psikhiatriya i psikhofarmakoterapiya: zhurnal im. P.B. Gannushkina. 2002; (2): 76-78. (In Russ.)
Guaiana G. Hydroxyzine for generalised anxiety disorder / G.Guaiana, C. Barbui, A. Cipriani // Cochrane Database Syst Rev. - 2010. - Vol. (12). - CD006815. - DOI: 10.1002/14651858.CD006815.pub2
Chessick C.A. Azapirones for generalized anxety disorder / C. A. Chessick, M. H. Allen, M. Thaseet al. // Cochrane Database Syst. Rev. - 2006. - Vol. (3). - CD006115.
Dzampaev A. T., Suvorova I. A., Damulin I. V. [Clinical potential and prospects of buspirone in the therapy of anxiety disorders]. Zhurnal nevrologii i psikhiatrii im. S.S. Korsakova. 2014; 114(8): 94-104. (In Russ.)
Stein D. J. Efficacy and safety of agomelatine 25-50 mg/day versus escitalopram 10-20 mg/day in severe generalised anxiety disorder / D. J.Stein, J. P. Khoo, M. van Ameringen et al. // European Neuropsychopharmacology. - 2017. - Vol. 27, № 4 (S1). - S1003. - DOI: 10.1016/S0924-977X(17)31762-5
Stein D. J., Khoo J. P., Ahokas A. A., et al. 12-week double-blind randomized multicenter study of efficacy and safety of agomelatine (25-50 mg/day) versus escitalopram (10-20 mg/day) in out-patients with severe generalized anxiety disorder. European Neuropsychopharmacology. 2018; 28(8): 970-979. doi: 10.1016/j.euroneuro.2018.05.006
Stein D. J. Efficacy of Agomelatine in Generalized Anxiety Disorder: A Randomized, Double-Blind, Placebo-Controlled Study / D. J. Stein, A. A. Ahokas, C. De Bodinat // J. Clin. Psychopharmacol. - 2008. - Vol. 28. - P. 561-566. - DOI: 10.1097/JCP.0b013e318184ff5b
Bykov Yu.V. Agomelatine: Expanded Indications in Psychiatry, Neurology, and Narcology (Literature Review) / Yu. V. Bykov, R. A. Bekker // Psychiatry and Psychopharmacotherapy: named after P.B. Gannushkin. - 2018. - No. 3-4. - P. 4-18.
Yee A. Vortioxetine Treatment for Anxiety Disorder: A Meta-Analysis Study / A. Yee, C. G. Ng, H. S. Loh // Curr. Drug Targets. - 2018. - Vol. 19(12). - P. 1412-1423. - doi: 10.2174/1389450118666171117131151
Bekker R.A. Trittico (Trazodone) - A Unique Serotonergic Antidepressant with a Number of Additional Properties / R. A. Bekker, Yu. V. Bykov // Psychiatry and Psychopharmacotherapy: named after P.B. Gannushkin. - 2018. - No. 3-4. - P. 51-62.
Bogolepova A.N. Modern Approaches to the Therapy of Anxiety Disorders in Elderly Patients / A. N. Bogolepova, E. A. Kovalenko, E. V. Makhnovich // Medical Council. - 2017. - No. 5. - P. 60-64.
Vorobyova O.V. Ways to Improve the Effectiveness of Therapy for Anxiety Disorders in the Nervous Diseases Clinic / O. V. Vorobyova // Psychiatry and Psychopharmacotherapy. - 2016. - No. 1. - P. 34-39.
Karavaeva T.A. Principles and Algorithms of Psychotherapy for Neurotic-Level Anxiety Disorders (Anxiety-Phobic, Panic, and Generalized Anxiety Disorders) / T. A. Karavaeva, A. V. Vasilyeva, S. V. Poltorak // V.M. Bekhterev Review of Psychiatry and Medical Psychology. - 2016. - No. 4. - P. 42-51.
Cuijpers P. Adding psychotherapy to antidepressant medication in depression and anxiety disorders: a meta-analysis / P. Cuijpers, M. Sijbrandij, S. L. Koole et al. // World Psychiatry. - 2014. - Vol. 13(1). - P. 56-67. - DOI: 10.1002/wps.20089
Turk C. L. Emotion dysregulation in generalized anxiety disorder: a comparison with social anxiety disorder / C. L. Turk, R. G. Heimberg, J. A. Luterek et al. // Cognitive Therapy and Research. - 2005. - Vol. 29 (1). - P. 89-106. - DOI: 10.1007/s10608-005-1651-1
Montero-Marin J. Is cognitive-behavioural therapy more effective than relaxation therapy in the treatment of anxiety disorders? A meta-analysis / J. Montero-Marin, J. Garcia-Campayo, A. Lopez-Montoyo et al. // Psychol. Med. - 2018. - Vol. 48(9). - P. 1427-1436. - doi: 10.1017/S0033291717003099.
Khoury B. Mindfulness-based therapy: a comprehensive meta-analysis / B. Khoury, T. Lecomte, G. Fortin et al. // Clin. Psychol. Rev. - 2013. - Vol. 33(6). - P. 763-771. http://dx.doi.org/10.1016/j.cpr.2013.05.005
Hall J. Efficacy of Cognitive Behavioral Therapy for Generalized Anxiety Disorder in Older Adults: Systematic Review, Meta-Analysis, and Meta-Regression / J. Hall, S. Kellett, R. Berrios et al. // Am. J. Geriatr. Psychiatry. - 2016. - Vol. 24(11). - P. 1063-1073. - doi: 10.1016/j.jagp.2016.06.006.
Cuijpers P. Relative effects of cognitive and behavioral therapies on generalized anxiety disorder, social anxiety disorder and panic disorder: A meta-analysis / P. Cuijpers, C. Gentili, R. M. Banos et al. // J. Anxiety Disord. - 2016. - Vol. 43. - P. 79-89. - doi: 10.1016/j.janxdis.2016.09.003.
Sayakin V.Yu. Specifics of the Cognitive-Behavioral Approach to the Problem of Generalized Anxiety Disorder / V. Yu. Sayakin // Higher Education Today. - 2018. - No. 6. - P. 55-57.
Kholmogorova A.B. Cognitive-Behavioral Models and Treatment Methods for Generalized Anxiety Disorder / A. B. Kholmogorova // Modern Therapy of Mental Disorders. - 2014. - No. 1. - P. 19-24.
Cape J. Brief psychological therapies for anxiety and depression in primary care: meta-analysis and meta-regression / J. Cape, C. Whittington, M. Buszewicz et al. // BMC Med. - 2010. - Vol. 8. - P. 38. - DOI: 10.1186/1741-7015-8-38
Gersh E. Systematic review and meta-analysis of dropout rates in individual psychotherapy for generalized anxiety disorder / E. Gersh, D. J. Hallford, S. M. Rice et al. // J. Anxiety Disord. - 2017. - Vol. 52. - P. 25-33. - doi: 10.1016/j.janxdis.2017.10.001.
Romera I. Generalized anxiety disorder, with or without co-morbid major depressive disorder, in primary care: prevalence of painful somatic symptoms, functioning and health status / I. Romera, S. Fernandez-Perez, B. L. Montejo et al. // J. Affect. Disord. - 2010. - Vol. 127. - P. 160-168. - DOI: 10.1016/j.jad.2010.05.009
Yonkers K. A. Factors predicting the clinical course of generalized anxiety disorder / K. A. Yonkers, I. R. Dyck, M. G. Warshaw, M. B. Keller // British Journal of Psychiatry. - 2000. - Vol. 176. - P. 544-549. - DOI: 10.1192/bjp.176.6.544
Sharma A., Verbeke W. J. M. I. Understanding importance of clinical biomarkers for diagnosis of anxiety disorders using machine learning models // PloS One. - 2021. - Vol. 16. - No. 5. - P. e0251365.
Almis B. H., Aksoy I. Mean platelet volume level in patients with generalized anxiety disorder // Psychiatry and Clinical Psychopharmacology. - 2018. - Vol. 28. - No. 1. - P. 43-47.
Kuczmierczyk A. R. et al. Serum cholesterol levels in patients with generalized anxiety disorder (GAD) and with GAD and comorbid major depression // The Canadian Journal of Psychiatry. - 1996. - Vol. 41. - No. 7. - P. 465-468.
Simon N. M. et al. Hypothyroidism and hyperthyroidism in anxiety disorders revisited: new data and literature review // Journal of Affective Disorders. - 2002. - Vol. 69. - No. 1-3. - P. 209-217.
Grillon C., Buchsbaum M. S. EEG topography of response to visual stimuli in generalized anxiety disorder // Electroencephalography and Clinical Neurophysiology. - 1987. - Vol. 66. - No. 4. - P. 337-348.
Siragusa M. A. et al. A systematic review of ultrasound imaging and therapy in mental disorders // Progress in Neuro-Psychopharmacology and Biological Psychiatry. - 2020. - Vol. 101. - P. 109919.
Paulesu E. et al. Neural correlates of worry in generalized anxiety disorder and in normal controls: a functional MRI study // Psychological Medicine. - 2010. - Vol. 40. - No. 1. - P. 117.
Pittig A. et al. Heart rate and heart rate variability in panic, social anxiety, obsessive-compulsive, and generalized anxiety disorders at baseline and in response to relaxation and hyperventilation // International Journal of Psychophysiology. - 2013. - Vol. 87. - No. 1. - P. 19-27.
Zhang Y. et al. Duloxetine in treating generalized anxiety disorder in adults: A meta-analysis of published randomized, double-blind, placebo-controlled trials // Asia-Pacific Psychiatry. - 2016. - Vol. 8. - No. 3. - P. 215-225.
Boschen M. J. A meta-analysis of the efficacy of pregabalin in the treatment of generalized anxiety disorder // The Canadian Journal of Psychiatry. - 2011. - Vol. 56. - No. 9. - P. 558-566.
Rickels K. et al. Antidepressants for the treatment of generalized anxiety disorder: a placebo-controlled comparison of imipramine, trazodone, and diazepam // Archives of General Psychiatry. - 1993. - Vol. 50. - No. 11. - P. 884-895.
Min-cai Q., Ju-shui S. U. N. Venlafaxine extended release (24 patients) vs clomipramine (25 patients) in treatment of generalized anxiety disorder // Chinese Journal of New Drugs and Clinical Remedies. - 2004. - Vol. 2.
Khan A. et al. Extended-release quetiapine fumarate (quetiapine XR) as adjunctive therapy in patients with generalized anxiety disorder and a history of inadequate treatment response: a randomized, double-blind study // Ann. Clin. Psychiatry. - 2013. - Vol. 25. - No. 4. - P. E7-E22.
Brawman-Mintzer O., Knapp R. G., Nietert P. J. Adjunctive risperidone in generalized anxiety disorder: a double-blind, placebo-controlled study // The Journal of Clinical Psychiatry. - 2005. - Vol. 66. - No. 10. - P. 1321-1325. Pollack M. H. et al.
Pollack M. H., Simon N. M., Zalta A. K., Worthington J. J., Hoge E. A., Mick E., Kinrys G., Oppenheimer J. Olanzapine augmentation of fluoxetine for refractory generalized anxiety disorder: a placebo controlled study // Biological Psychiatry. - 2006. - Vol. 59. - No. 3. - P. 211-215.
Menza M. A., Dobkin R. D., Marin H. An open-label trial of aripiprazole augmentation for treatment-resistant generalized anxiety disorder // J. Clin. Psychopharmacol. - 2007. - Vol. 27. - No. 2. - P. 207-210.
Worthington J. J., Kinrys G., Wygant L. E., Pollack M. H. Aripiprazole as an augmentor of selective serotonin reuptake inhibitors in depression and anxiety disorder patients // Int. Clin. Psychopharmacol. - 2005. - Vol. 20. - No. 1. - P. 9-11.
Smulevich A. B., Andryushchenko A. V., Romanov D. V. Psychopharmacotherapy of borderline-level anxiety disorders (a comparative study of the anxiolytic effect of Afobazole and oxazepam in patients with adjustment disorders and generalized anxiety disorder) // RMJ (Russian Medical Journal). - 2006. - Vol. 14, No. 9. - P. 725-730.
Avedisova A. S., Chakhava V. O., Less Yu.Э., Malygin Ya.V. The new anxiolytic Afobazole in the therapy of generalized anxiety disorder (results of a comparative study with diazepam) // Psychiatry and Psychopharmacotherapy. - 2006. - Vol. 8, - No. 3. - P. 13-16.
Neznamov G.G., Syunyakov S.A., Chumakov D.V. et al. [New anxiolytic Afobazole: results of a comparative clinical study with diazepam in generalized anxiety disorder] // Psychiatry and Psychopharmacotherapy. 2006. - Vol. 8. - No. 4. - P. 17-23
Dorozhenok I.Yu., Terentyeva M.A. [Afobazole in the treatment of anxiety disorders in dermatological inpatients] // Russian Medical Journal. 2007. - Vol. 15, - No. 19. - P. 1379-1382.
Ivanov S.V. [Afobazole® in the treatment of anxiety disorders in general practice] // Effective Pharmacotherapy. Neurology and Psychiatry. - 2010. - No. 2
Veltishchev D.Yu. [Diagnosis and pharmacotherapy of the anxious variant of adjustment disorders: the anxiolytic etifoxine (Stresam) in clinical and experimental studies] // Social and Clinical Psychiatry. - 2010 - Vol. 20, No. 1 - P. 86-90.
Borodin V.I., Zubko V.G. [Broad prospects for the use of the new anxiolytic Stresam] // Russian Medical Journal. - 2012 - Vol. 17, No. 11 - P. 806-808.
Servant D., Graziani P., Moyse D., Parquet P. Treatment of adjustment disorders with anxiety: efficacy and safety of etifoxine in a double blind controlled study // Encephale. - 1998 - Vol. 24 - P. 569-574.
Biryukova E.V. [Application of alpha-theta EEG biofeedback training in anxiety disorders resistant to psychopharmacotherapy (an open randomized controlled trial) / Biryukova E.V., Timofeev I.V., Mosolov S.N.] // V.M. Bekhterev Review of Psychiatry and Medical Psychology. - 2010. - No. 1. - P. 15-20.
Adaptation of L.N. Sobchik's method. V.P. Serbsky Institute of Forensic Psychiatry, 1971. Sobchik L.N. [Standardized Multifactorial Personality Questionnaire SMIL (MMPI): Practical Guide]. - M.: Rech, 2007. - 224 p.
Ammon G. Das Verstandniseines Entwicklungsdefizitsvon Ich-Strukturenin Personlichkeitundumgebender Gruppeals Grundlagefiir Wisscnschaftund Praxiseiner Dynamischen Psychiatrie. / G. Ammon. // Dynamische Psychiatrie. - 1978. - Jg. 11. - P. 120-140.
Bazhin E.F. [Method for studying the level of subjective control] / E.F. Bazhin, E.A. Golynkina, A.M. Etkind // Psychological Journal. - Vol. 5. - 1984. - No. 3. - P. 152-162.
Nazyrov R.K. [Typology of psychotherapeutic targets and its use to improve the quality of individual psychotherapeutic programs in the treatment of patients with neurotic disorders] / R.K. Nazyrov, S.V. Logacheva, M.B. Remeslo, V.V. Kholyavko, I.O. Pavlovsky // Methodological Recommendations. - St. Petersburg: V.M. Bekhterev NIPNI Publishing House. - 2011.
Wasserman L.I. [Psychological diagnostics of the Coping Style Index: methodological guide for doctors and psychologists] / L.I. Wasserman, O.F. Eryshev, E.B. Klubova et al. // St. Petersburg: V.M. Bekhterev NIPNI. - 1998. - 48 p.
Wasserman L.I. [Methodology for psychological diagnosis of coping strategies with stress and problem situations: Guide for physicians and medical psychologists] / L.I. Wasserman, B.V. Iovlev, E.R. Isaeva et al. // V.M. Bekhterev NIPNI Publishing House. - St. Petersburg, 2009. - 40 p.
Kornilova T.V. [Melbourne Decision Making Questionnaire: Russian-language adaptation] / T.V. Kornilova // Psychological Studies. - 2013. - Vol. 6. - No. 31.
Isurina G.L. [The "KON-2006" questionnaire – a new method for studying neurotic personality traits] / G.L. Isurina, I.V. Grandilevskaya, P.K. Trombcinski // Medical Psychology in Russia: Electronic Scientific Journal. - 2017. - Vol. 9, No. 6(47)
Nikolaev N.A. [Russian universal questionnaire for the quantitative assessment of treatment adherence (KOP-25)] / N.A. Nikolaev, Yu.P. Skirdenko // Clinical Pharmacology and Therapy. - 2018. - No. 27(1). - P. 74 - 78.
Neznanov N.G., Martynikhin I.A., Mosolov S.N. [Diagnosis and therapy of anxiety disorders in the Russian Federation: results of a survey of psychiatrists] // Modern Therapy of Mental Disorders. - 2017, No. 2, P. 2-15
Vilyanov V.B., Kremenitskaya S.A., Solovyova N.V. [Efficacy of sulpiride in patients with anxiety disorders depending on blood serum serotonin concentration] // S.S. Korsakov Journal of Neurology and Psychiatry. - 2015. - Vol. 115. - No. 10. - P. 62-65.
Fu J., Peng L., Li X. The efficacy and safety of multiple doses of vortioxetine for generalized anxiety disorder: a meta-analysis // Neuropsychiatric disease and treatment. - 2016. - Vol. 12. - P. 951.
Pae C.U. et al. Vortioxetine, a multimodal antidepressant for generalized anxiety disorder: a systematic review and meta-analysis // Journal of psychiatric research. - 2015. - Vol. 64. - P. 88-98.
Garanyan N.G., Sharapova A.V. [On the concept of workplace anxiety disorders, its theoretical foundations and empirical verification] // Modern Therapy of Mental Disorders. – 2023. – No. 3. – P. 32–40. – DOI: 10.21265/PSYPH.2023.18.96.004
Stein DJ, Ahokas A, Marquez MS, Hoschl C, Oh KS, Jarema M, et al. (2014). Agomelatine in generalized anxiety disorder: an active comparator and placebo-controlled study. // J Clin Psychiatry 75:362-368.
Stein DJ, Khoo JP, Picarel-Blanchot F, Olivier V, Van Ameringen M (2021). Efficacy of agomelatine 25-50mg for the treatment of anxious symptoms and functional impairment in generalized anxiety disorder: a meta-analysis of three placebo-controlled studies. // Adv Ther 38:1567-1583.
Mosolov S.N., Martynikhin I.A., Syunyakov T.S., Galankin T.L., Neznanov N.G. Incidence of the Diagnosis of Anxiety Disorders in the Russian Federation: Results of a Web- Based Survey of Psychiatrists. // Neurology and Therapy. 2021; 1-14 https://doi.org/10.1007/s40120-021-00277-w
Zolotareva A.A. [Adaptation of the Russian version of the Generalized Anxiety Disorder-7 (GAD-7) scale] // Counseling Psychology and Psychotherapy. 2023. Vol. 31. No. 4. P. 31-46. DOI: 10.17759/cpp.2023310402
Ababkov V.A., Berebin M.A., Bespalko I.G., Bizyuk A.P., Bocharov V.V., Wasserman L.I., Vuks A.Ya., Iovlev B.V., Isaeva E.R., Karpova E.B., Malkova E.E., Malkova L.D., Novozhilova M.Yu., Tkachenko S.V., Trifonova E.A., Chervinskaya K.R., Shchelkova O.Yu. [Psychological diagnostics of emotional and personality disorders; Collaborative monograph] / Ed. by L.I. Wasserman, O.Yu. Shchelkova. St. Petersburg: Skifiya-print, 2014. - 408 p.
Bleykher, V.M. [Clinical pathopsychology: A guide for physicians and clinical psychologists] / V.M. Bleykher, I.V. Kruk, S.N. Bokov. - M.: MPSI, 2009. - 624 p.
Wasserman L.I., Shchelkova O.Yu. [Medical psychodiagnostics: Theory, practice, training]. - St. Petersburg - M.: Akademiya, 2003. - 736 p.
Semyonova N.V., Neznanov N.G. [Diagnosis and treatment of mental and addictive disorders: Modern approaches. Collection of methodological recommendations] / Comp. by N.V. Semyonova, under the general editorship of N.G. Neznanov. Issue 6. — St. Petersburg: Publishing and Printing Company "KOSTA", 2023. — 536 p.
Order of the Ministry of Health of the Russian Federation No. 804n dated October 13, 2017 "On approval of the nomenclature of medical services" (with amendments and additions dated April 16, 2019, March 5, September 24, 2020)
Lyashkovskaya S.V., Karavaeva T.A. [Organizational aspects of the activities of psychotherapists and clinical psychologists engaged in the provision of psychotherapeutic care] // [Diagnosis and treatment of mental and addictive disorders: Modern approaches. Collection of methodological recommendations] / Comp. by N.V. Semyonova, under the general editorship of N.G. Neznanov. Issue 5. — St. Petersburg: Publishing and Printing Company "KOSTA", 2022.— P. 434-455
Enkelmann R. 1991. Alprazolam versus buspirone in the treatment of outpatients with generalized anxiety disorder. // Psychopharmacology (Berl) 105:428-32.
Lydiard RB, Ballenger JC, Rickels K. 1997. A double-blind evaluation of the safety and efficacy of abecarnil, alprazolam, and placebo in outpatients with generalized anxiety disorder. Abecarnil Work Group. // J Clin Psychiatry 58 Suppl 11:11-8.
Moller HJ, Volz HP, Reimann IW, Stoll KD. 2001. Opipramol for the treatment of generalized anxiety disorder: a placebo-controlled trial including an alprazolam-treated group. J Clin Psychopharmacol 21:59-65.
Power KG, Jerrom DWA, Simpson RJ, Mitchell MJ, Swanson V. 1989. A controlled comparison of cognitive behavior therapy, diazepam and placebo in the management of generalized anxiety. // Behav Psychother 17:1-14.
Rickels K, Schweizer E, DeMartinis N, Mandos L, Mercer C. 1997. Gepirone and diazepam in generalized anxiety disorder: a placebo-controlled trial. // J Clin Psychopharmacol 17:272-7.
Ansseau M, Olie JP, von Frenckell R, Jourdain G, Stehle B, Guillet P. 1991. Controlled comparison of the efficacy and safety of four doses of suriclone, diazepam, and placebo in generalized anxiety disorder. // Psychopharmacology (Berl) 104:439-43.
Boyer WF, Feighner JP. 1993. A placebo-controlled double-blind multicenter trial of two doses of ipsapirone versus diazepam in generalized anxiety disorder. // Int Clin Psychopharmacol 8:173-6.
Fontaine R, Mercier P, Beaudry P, Annable L, Chouinard G. 1986. Bromazepam and lorazepam in generalized anxiety: a placebo-controlled study with measurement of drug plasma concentrations. // Acta Psychiatr Scand 74:45 1-8.
Rickels K, Shiovitz TM, Ramey TS, Weaver JJ, Knapp LE, Miceli JJ. 2012. Adjunctive therapy with pregabalin in generalized anxiety disorder patients with partial response to SSRI or SNRI treatment. // Int Clin Psychopharmacol 27:142-50.
[Federal Guidelines for Physicians on Drug Use (Formulary System)] / Ed. by A.G. Chuchalin, Issue III, - Moscow, 2002.
Bandelow B, Chouinard G, Bobes J, Ahokas A, Eggens I, Liu S, Eriksson H. 2010. Extended-release quetiapine fumarate (quetiapine XR): a once-daily monotherapy effective in generalized anxiety disorder. Data from a randomized, double-blind, placebo- and active- controlled study. // Int J Neuropsychopharmacol 13:305-20.
Khan A, Joyce M, Atkinson S, Eggens I, Baldytcheva I, Eriksson H. 2011. A randomized, double-blind study of once-daily extended release quetiapine fumarate (quetiapine XR) monotherapy in patients with generalized anxiety disorder. // J Clin Psychopharmacol 31:41828.
Katzman MA, Brawman-Mintzer O, Reyes EB, Olausson B, Liu S, Eriksson H. 2011. Extended release quetiapine fumarate (quetiapine XR) monotherapy as maintenance treatment for generalized anxiety disorder: a long-term, randomized, placebo-controlled trial. // Int Clin Psychopharmacol 26:11-24.
Merideth C, Cutler AJ, She F, Eriksson H. 2012. Efficacy and tolerability of extended release quetiapine fumarate monotherapy in the acute treatment of generalized anxiety disorder: a randomized, placebo controlled and active-controlled study. // Int Clin Psychopharmacol 27:4054.
Mezhebovsky I, Magi K, She F, Datto C, Eriksson H. 2013. Double-blind, randomized study of extended release quetiapine fumarate (quetiapine XR) monotherapy in older patients with generalized anxiety disorder. // Int J Geriatr Psychiatry 28:615-25.
Ferreri M, Hantouche EG, Billardon M. 1994. Interet de l"hydroxyzine dans le trouble anxidtd gdneralisde: etude controle en double aveugle versus placebo. // Encdphale 20:785-91.
Darcis T, Ferreri M, Natens J, Burtin B, Deram P. 1995. A multicentre double-blind placebo-controlled study investigating the anxiolytic efficacy of hydroxyzine in patients with generalized anxiety. // Hum Psychopharmacol 10:181-187.
Llorca PM, Spadone C, Sol O, et al. 2002. Efficacy and safety of hydroxyzine in the treatment of generalized anxiety disorder: a 3-month double-blind study. // J Clin Psychiatry 63:1020-7.
Feighner JP, Merideth CH, Hendrickson GA. 1982. A double-blind comparison of buspirone and diazepam in outpatients with generalized anxiety disorder. // J Clin Psychiatry 43:103-8.
Laakmann G, Schule C, Lorkowski G, Baghai T, Kuhn K, Ehrentraut S. 1998. Buspirone and lorazepam in the treatment of generalized anxiety disorder in outpatients. // Psychopharmacology (Berl) 136:357-66.
Sramek JJ, Tansman M, Suri A, Hornig-Rohan M, Amsterdam JD, Stahl SM, Weisler RH, Cutler NR. 1996. Efficacy of buspirone in generalized anxiety disorder with coexisting mild depressive symptoms. // J Clin Psychiatry 57:287-91 .
Ivashchenko AA, Morozova MA, Vostokova NV et al. Safety and efficacy of aviandr in patients with generalized anxiety disorder: A multicenter, randomized, double-blind, placebo-controlled, dose-finding, pilot study. // J Psychiatr Res. 2021 Nov; 143:436-444. doi: 10.1016/j.jpsychires.2021.10.008.
Ivachtchenko AV, Lavrovsky Y, Okun I. AVN-101: A Multi-Target Drug Candidate for the Treatment of CNS Disorders. // J Alzheimers Dis. 2016 May 25;53(2):583-620. doi: 10.3233/JAD-151146.
Pandina GJ, Canuso CM, Turkoz I, Kujawa M, Mahmoud RA. 2007. Adjunctive risperidone in the treatment of generalized anxiety disorder: a double-blind, prospective, placebo-controlled, randomized trial. // Psychopharmacol Bull 40:41-57.
Aliyev NA, Aliyev ZN. 2008. Valproate (depakine-chrono) in the acute treatment of outpatients with generalized anxiety disorder without psychiatric comorbidity: Randomized, double-blind placebo-controlled study. // European Psychiatry 23:109-114.
Bidzan L, Mahableshwarkar AR, Jacobsen P, Yan M, Sheehan DV. 2012. Vortioxetine (Lu AA21004) in generalized anxiety disorder: results of an 8-week, multinational, randomized, double-blind, placebo-controlled clinical trial. // Eur Neuropsychopharmacol 22:84757.
Baldwin DS, Loft H, Florea I. 2012. Lu AA21004, a multimodal psychotropic agent, in the prevention of relapse in adult patients with generalized anxiety disorder. Int Clin Psychopharmacol 27:197-207.
Lenze EJ, Mulsant BH, Shear MK, Dew MA, Miller MD, Pollock BG, Houck P, Tracey B, Reynolds CF, 3rd. 2005. Efficacy and tolerability of citalopram in the treatment of late- life anxiety disorders: results from an 8-week randomized, placebo-controlled trial. // Am J Psychiatry 162:146-50.
Davidson J, Yaryura-Tobias J, DuPont R, Stallings L, Barbato LM, van der Hoop RG, Li D. 2004. Fluvoxamine-controlled release formulation for the treatment of generalized social anxiety disorder. // J Clin Psychopharmacol 24:118-25.
Satoshi A, Tajima O, Koyama T. Fluvoxamine treatment of generalized social anxiety disorder in Japan: a randomized double-blind, placebo-controlled study. // International journal of Neuropsychopharmacology 10.2 (2007): 263-274
Salakhova A.I., Yagubov M.I. [Sexual dysfunction during antidepressant use in patients with anxiety and depressive disorders (management and correction algorithm)] // Modern Therapy of Mental Disorders. — 2024. — No. 2. — P. 56-67. — DOI: 10.21265/PSYPH.2024.31.31.006
Henssler J, Heinz A, Brandt L, Bschor T. Antidepressant Withdrawal and Rebound Phenomena. Dtsch Arztebl Int. 2019; 116(20): 355-361.
Tint A., Haddad P.M., Anderson I.M. The effect of rate of antidepressant tapering on the incidence of discontinuation symptoms: a randomised study. J Psychopharmacol 2008; 22: 330-332.
Schatzberg AF, Blier P, Delgado PL, Fava M, Haddad PM, Shelton RC. Antidepressant discontinuation syndrome: consensus panel recommendations for clinical management and additional research. J Clin Psychiatry. 2006;67 Suppl 4:27-30.
Khasanova A.K., Mosolov S.N. [Antidepressant discontinuation syndrome (prevention and correction algorithm)] // Modern Therapy of Mental Disorders. - 2023. - No. 2. - P. 37-47. - DOI: 10.21265/PSYPH.2023.15.79.005
Warner C.H., Bobo W., Warner C. et al. Antidepressant discontinuation syndrome // American Family Physician. - 2006. - Vol. 74 (3). - Pp. 449-456.
Orvati Aziz M, Mehrinejad SA, Hashemian K, Paivastegar M. Integrative therapy (short-term psychodynamic psychotherapy & cognitive-behavioral therapy) and cognitive- behavioral therapy in the treatment of generalized anxiety disorder: A randomized controlled trial. Complement Ther Clin Pract. 2020;39:101122. doi: 10.1016/j.ctcp.2020.101122.
Nordahl HM, Borkovec TD, Hagen R, Kennair LEO, Hjemdal O, Solem S, Hansen B, Haseth S, Wells A. Metacognitive therapy versus cognitive-behavioural therapy in adults with generalised anxiety disorder. BJPsych Open. 2018 Sep 11;4(5):393-400. doi: 10.1192/bjo.2018.54. PMID: 30294448; PMCID: PMC6171331.
Sadeghi R, Mokhber N, Mahmoudi LZ, Asgharipour N, Seyfi H. A systematic review and meta-analysis on controlled treatment trials of metacognitive therapy for anxiety disorders. J Res Med Sci. 2015 Sep;20(9):901-9. doi: 10.4103/1735-1995.170632. PMID: 26759579; PMCID: PMC4696377.
Rawat A, Sangroula N, Khan A, Faisal S, Chand A, Yousaf RA, Muhammad N, Yousaf H. Comparison of Metacognitive Therapy Versus Cognitive Behavioral Therapy for Generalized Anxiety Disorder: A Meta-Analysis of Randomized Control Trials. Cureus. 2023 May 20;15(5):e39252. doi: 10.7759/cureus.39252. PMID: 37342751; PMCID: PMC10277900.
Arch, J. J., Eifert, G. H., Davies, C., Vilardaga, J. C. P., Rose, R. D., & Craske, M. G. (2012). Randomized clinical trial of cognitive behavioral therapy (CBT) versus acceptance and commitment therapy (ACT) for mixed anxiety disorders. Journal of Consulting and Clinical Psychology, 80(5), 750-765. https://doi.org/10.1037/a0028310
Ruiz, F. J., Pena-Vargas, A., Ramirez, E. S., Suarez-Falcon, J. C., Garcia-Martin, M. B., Garcia-Beltran, D. M., Henao, A. M., Monroy-Cifuentes, A., & Sanchez, P. D. (2020). Efficacy of a two-session repetitive negative thinking-focused acceptance and commitment therapy (ACT) protocol for depression and generalized anxiety disorder: A randomized waitlist control trial. Psychotherapy, 57(3), 444-456. https://doi.org/10.1037/pst0000273
Hoge EA, Bui E, Palitz SA, Schwarz NR, Owens ME, Johnston JM, Pollack MH, Simon NM. The effect of mindfulness meditation training on biological acute stress responses in generalized anxiety disorder. Psychiatry Res. 2018 Apr;262:328-332. doi: 10.1016/j.psychres.2017.01.006.
Hoge EA, Bui E, Marques L, Metcalf CA, Morris LK, Robinaugh DJ, Worthington JJ, Pollack MH, Simon NM. Randomized controlled trial of mindfulness meditation for generalized anxiety disorder: effects on anxiety and stress reactivity. J Clin Psychiatry. 2013 Aug;74(8):786-92. doi: 10.4088/JCP.12m08083.
Winklerfelt Hammarberg S, Toth-Pal E, Jansson-Frojmark M, Lundgren T, Westman J, Bohman B. Intolerance-of-uncertainty therapy versus metacognitive therapy for generalized anxiety disorder in primary health care: A randomized controlled pilot trial. PLoS One. 2023 Jun 14;18(6):e0287171. doi: 10.1371/journal.pone.0287171.
Hui C, Zhihui Y. Group cognitive behavioral therapy targeting intolerance of uncertainty: a randomized trial for older Chinese adults with generalized anxiety disorder. Aging Ment Health. 2017 Dec;21(12):1294-1302. doi: 10.1080/13607863.2016.1222349.
Wilson EJ, Abbott MJ, Norton AR. The impact of psychological treatment on intolerance of uncertainty in generalized anxiety disorder: A systematic review and meta-analysis. J Anxiety Disord. 2023 Jun;97:102729. doi: 10.1016/j.janxdis.2023.102729.
Dugas MJ, Ladouceur R. Treatment of GAD. Targeting intolerance of uncertainty in two types of worry. Behav Modif. 2000;24(5):635-57. doi: 10.1177/0145445500245002
Donker, T., Petrie, K., Proudfoot, J., Clarke, J., Birch, M. R., & Christensen, H. (2013). Smartphones for smarter delivery of mental health programs: A systematic review. Journal of Medical Internet Research, 15, e247.
Lindner, P., Miloff, A., Hamilton, W., Reuterskiold, L., Andersson, G., Powers, M., &Carlbring, P. (2017). Creating state of the art, next-generation virtual reality exposure therapies for anxiety disorders using consumer hardware platforms: Design considerations and future direction. Cognitive Behaviour Therapy, 46, 404-420.
Miller, C. B., Gu, J., Henry, A. L., Davis, M. L., Espie, C. A., Stott, R., Heinz, A. J., Bentley, K. H., Goodwin, G. M., Gorman, B. S., Craske, M. G., & Carl, J. R. (2021). Feasibility and efficacy of a digital CBT intervention for symptoms of generalized anxiety disorder: A randomized multiple-baseline study. Journal of Behavior Therapy and Experimental Psychiatry, 70,101609. https://doi.org/10.1016Zi.jbtep.2020.101609
Eilert N, Enrique A, Wogan R, Mooney O, Timulak L, Richards D. The effectiveness of Internet-delivered treatment for generalized anxiety disorder: An updated systematic review and meta-analysis. Depress Anxiety. 2021 Feb;38(2):196-219. doi: 10.1002/da.23115
Berryhill, M. B., Halli-Tierney, A., Culmer, N., Williams, N., Betancourt, A., King, M., & Ruggles, H. (2019). Videoconferencing psychological therapy and anxiety: A systematic review. Family Practice, 36(1), 53-63. https://doi.org/10.1093/fampra/cmy072
Trenoska Basile V, Newton-John T, Wootton BM. Remote cognitive-behavioral therapy for generalized anxiety disorder: A preliminary meta-analysis. J Clin Psychol. 2022 Dec;78(12):2381-2395. doi: 10.1002/jclp.23360. Epub 2022 Apr 11. PMID: 35403706; PMCID: PMC9790363.
Christensen, H., Griffiths, K. M., & Farrer, L. (2009). Adherence in internet interventions for anxiety and depression. Journal of Medical Internet Research, 11(2), e13. https://doi.org/10.2196/jmir.1194
Brenes GA, Danhauer SC, Lyles MF, Hogan PE, Miller ME. Telephone-Delivered Cognitive Behavioral Therapy and Telephone-Delivered Nondirective Supportive Therapy for Rural Older Adults With Generalized Anxiety Disorder: A Randomized Clinical Trial. JAMA Psychiatry. 2015 Oct;72(10):1012-20. doi: 10.1001/jamapsychiatry.2015.1154
Brenes GA, Danhauer SC, Lyles MF, Anderson A, Miller ME. Long-Term Effects of Telephone-Delivered Psychotherapy for Late-Life GAD. Am J Geriatr Psychiatry. 2017 Nov;25(11):1249-1257. doi: 10.1016/j.jagp.2017.05.013
Abbass AA, Hancock JT, Henderson J, Kisely S. Short-term psychodynamic psychotherapies for common mental disorders. Cochrane Database Syst Rev. 2006 Oct 18;(4): CD004687. doi: 10.1002/14651858.CD004687.pub3. Update in: Cochrane Database Syst Rev. 2014 Jul 01;(7):CD004687. doi: 10.1002/14651858.CD004687.pub4
Salzer S, Winkelbach C, Leweke F, Leibing E, Leichsenring F. Long-term effects of short-term psychodynamic psychotherapy and cognitive-behavioural therapy in generalized anxiety disorder: 12-month follow-up. Can J Psychiatry. 2011 Aug;56(8):503-8. doi: 10.1177/070674371105600809
Leichsenring F, Salzer S, Jaeger U, Kachele H, Kreische R, Leweke F, Ruger U, Winkelbach C, Leibing E. Short-term psychodynamic psychotherapy and cognitive-behavioral therapy in generalized anxiety disorder: a randomized, controlled trial. Am J Psychiatry. 2009 Aug;166(8):875-81. doi: 10.1176/appi.ajp.2009.09030441
Andersson G, Paxling B, Roch-Norlund P, Ostman G, Norgren A, Almlov J, Geordn L, Breitholtz E, Dahlin M, Cuijpers P, Carlbring P, Silverberg F. Internet-based psychodynamic versus cognitive behavioral guided self-help for generalized anxiety disorder: a randomized controlled trial. Psychother Psychosom. 2012;81(6):344-55. doi: 10.1159/000339371. Epub 2012 Sep 6. PMID: 22964540.
Vasilyeva A.V., Karavaeva T.A., Kolesova Yu.P., Radionov D.S., Starunskaya D.A., Fomicheva M.A., Abdullaeva S.M. [Evaluation of the efficacy of a comprehensive medical and psychological treatment method for patients with insomnia]. V.M. Bekhterev Review of Psychiatry and Medical Psychology. - 2023. - Vol. 57, No. 4. - P. 30-41. doi:10.31363/2313-7053-2023-773
Khurshid KA. Comorbid Insomnia and Psychiatric Disorders: An Update. Innov Clin Neurosci. 2018 Apr 1;15(3-4):28-32
Khan IW, Juyal R, Shikha D, Gupta R. Generalized Anxiety disorder but not depression is associated with insomnia: a population based study. Sleep Sci. 2018 May-Jun;11(3):166-173. doi: 10.5935/1984-0063.20180031
Diefenbach G. J., Bragdon L.B., Zertuche L. et al. Repetitive Transcranial Magnetic Stimulation for Generalised Anxiety Disorder: A Pilot Randomised, Double-Blind, Sham-Controlled Trial // British Journal of Psychiatry.— 2016.— Vol. 209.— No 3.— P. 222-228.
Dilkov D., Hawken E. R., Kaludiev E., Milev R. Repetitive Transcranial Magnetic Stimulation of the Right Dorsal Lateral Prefrontal Cortex in the Treatment of Generalized Anxiety Disorder: A Randomized, Double-Blind Sham Controlled Clinical Trial // Progress in NeuroPsychopharmacology and Biological Psychiatry.— 2017.— Vol. 78.— P. 61-65.
Tolin DF, Davies CD, Moskow DM, Hofmann SG. Biofeedback and Neurofeedback for Anxiety Disorders: A Quantitative and Qualitative Systematic Review. // Adv Exp Med Biol. 2020;1191:265-289. doi: 10.1007/978-981-32-9705-0
Rice KM, Blanchard EB, Purcell M. Biofeedback treatments of generalized anxiety disorder: preliminary results. // Biofeedback Self Regul. 1993 Jun;18(2):93-105. doi: 10.1007/BF01848110.
Zafeiri E, Dedes V, Tzirogiannis K, et al. Managing anxiety disorders with the neurobiofeedback method of Brain Boy Universal Professional. // Health Psychology Research. 2022; 10(2). doi:10.52965/001c.35644
Sandhu JS., Maman P, Hitanshu A. Biofeedback Approach in The Treatment of Generalized Anxiety Disorder.// Iranian Journal of Psychiatry 2 (2007):90-95.
Zhang W, Du Y, Yang X, Wang E, Fang J, Liu Z, Wu S, Liu Q, Hu Y. Comparative efficacy of face-to-face and internet-based cognitive behavior therapy for generalized anxiety disorder: A meta-analysis of randomized controlled trial. Front Psychiatry. 2022 Jul 28; 13:832167. doi: 10.3389/fpsyt.2022.832167
Wilson EJ, Abbott MJ, Norton AR. The impact of psychological treatment on intolerance of uncertainty in generalized anxiety disorder: A systematic review and meta-analysis. J Anxiety Disord. 2023 Jun;97:102729. doi: 10.1016/j.janxdis.2023.102729. Epub 2023 May 20. PMID: 37271039.
Zainal NH, Newman MG. A randomized controlled trial of a 14-day mindfulness ecological momentary intervention (MEMI) for generalized anxiety disorder. Eur Psychiatry. 2023 Jan 16;66(1):e12. doi: 10.1192/j.eurpsy.2023.2. PMID: 36645098; PMCID: PMC9970156.
Fonseca NKOD, Costa MA, Gosmann NP, Dalle Molle R, Goncalves FG, Silva AC, Rodrigues Y, Silveira PP, Manfro GG. Emotional eating in women with generalized anxiety disorder. Trends Psychiatry Psychother. 2023; 45:e20210399. doi: 10.47626/2237-6089-2021- 0399
Strawn JR, Geracioti L, Rajdev N, Clemenza K, Levine A. Pharmacotherapy for generalized anxiety disorder in adult and pediatric patients: an evidence-based treatment review. Expert Opin Pharmacother. 2018 Jul;19(10):1057-1070. doi: 10.1080/14656566.2018.1491966. PMID: 30056792; PMCID: PMC6340395.
Garakani A, Murrough JW, Freire RC, Thom RP, Larkin K, Buono FD, Iosifescu DV. Pharmacotherapy of Anxiety Disorders: Current and Emerging Treatment Options. Front Psychiatry. 2020 Dec 23;1 1:595584. doi: 10.3389/fpsyt.2020.595584. PMID: 33424664; PMCID: PMC7786299.
Kostyukova E.G. [Generalized anxiety disorder: Fundamentals of diagnosis, therapy, and Russia-specific problems] // Modern Therapy of Mental Disorders. — 2024. — No. 2. — P. 23-31. — DOI: 10.21265/PSYPH.2024.31.31.003
Bystritsky A., Kerwin L.E., Feusner J.D. A preliminary study of fMRI-guided rTMS in the treatment of generalized anxiety disorder: 6-month follow-up // Journal of Clinical Psychiatry.— 2009.— No 70.— P. 431-432.
Mosolov S.N., Tsukarzi E.E., Maslenikov N.V. [Application of transcranial magnetic stimulation in psychiatry] / Ed. by S.N. Mosolov / - Ivanovo: Neurosoft, 2023, 576 p.
Henssler J, Heinz A, Brandt L, Bschor T. Antidepressant Withdrawal and Rebound Phenomena. // Dtsch Arztebl Int. 2019;116(20):355-361.
Babyuk I.A., Shults O.E. [Study of the efficacy of afobazole for the treatment of patients with generalized anxiety disorder] // P.B. Gannushkin Psychiatr. and Psychopharmacother. 2014, vol. 16, no. 3, p. 58.
Syunyakov T.S., Dorofeeva O.A., Seredenin S.B. [Results of a comparative study of the therapeutic equivalence of immediate-release and extended-release fabomotizole formulations] // Psychiatry and Psychopharmacotherapy. 2021; 1:4–10.
Chakhava V.O., Borukaev R.R. [Efficacy of Afobazole in generalized anxiety disorder under long-term therapy conditions] // Medical News. - 2011. - No. 1. - 15-21
[Psychotherapy: National Guidelines] / Ed. by A.V. Vasilyeva, T.A. Karavaeva, N.G. Neznanov. – Moscow: GEOTAR-Media, 2023. 992 p.
Lyashkovskaya S.V., Karavaeva T.A., Kondinsky A.G. [Improving the provision of medical-psychological and psychotherapeutic care in outpatient settings] [Diagnosis and treatment of mental and addictive disorders: Modern approaches. Collection of methodological recommendations] / Comp. by N.V. Semyonova, under the general editorship of N.G. Neznanov. Issue 6. — St. Petersburg: Publishing and Printing Company "KOSTA", 2023. — P. 5-32.
Lepilkina T.A., Beniashvili A.G., Starodubova A.V. et al. [Virtual reality for relaxation: Typology and efficacy factors] // Modern Therapy of Mental Disorders. — 2024. — No. 1. — P. 32–42. — DOI: 10.21265/PSYPH.2024.27.29.004.
Karavaeva T.A., Vasilyeva A.V., Isurina G.L., Aleksandrov A.A. Personalized approach in personality-oriented (reconstructive) psychotherapy: targets and strategies: guidelines // Diagnosis and treatment of mental and addictive disorders: modern approaches. Collection of guidelines / comp. by N.V. Semenova, under the general editorship of N.G. Neznanov. – Issue 4. – St. Petersburg: IPK "KOSTA", 2021. – P. 169-203
Alimemazine instructions for use. https://grls.rosminzdrav.ru/Grls_View_v2.aspx?routingGuid=a7a28289-17b6-4d64-a588-3aa73dc0a986
Appendix A1. Working Group Composition
Anna V. Vasilyeva – Doctor of Medical Sciences, Associate Professor, Chief Research Scientist 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.
Yury P. Zinchenko – Doctor of Psychological Sciences, Chief freelance specialist in medical psychology of the Russian Ministry of Health, Dean of the Faculty of Psychology at Lomonosov Moscow State University, Director of the Psychological Institute of the Russian Academy of Education, Professor, Full Member of the Russian Academy of Education, President of the Russian Psychological Society.
Elena R. Isaeva – Doctor of Psychological Sciences, Professor, Head of the Department of General and Clinical Psychology, Pavlov First Saint Petersburg State Medical University of the Russian Ministry of Health, Chief freelance specialist in medical psychology of the St. Petersburg Health Committee, Member of the Russian Society of Psychiatrists
Tatiana A. Karavaeva – 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 Research Scientist of the Department for the Treatment of Borderline Mental Disorders and Psychotherapy, 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, Saint Petersburg State University, Professor at the Department of General and Applied Psychology with Courses in Biomedical Disciplines and Pedagogy, St. Petersburg State Pediatric Medical University of the Russian Ministry of Health, Leading Research Scientist at the Scientific Department of Innovative Methods of Therapeutic Oncology and Rehabilitation, N.N. Petrov National Medical Research Center of Oncology of the Russian Ministry of Health, Vice-President of the Russian Psychotherapeutic Association (RPA), Head of the Working Group on the Preparation of Clinical Guidelines for "Generalized Anxiety Disorder", Member of the Russian Society of Psychiatrists
Elena B. Mizinova – Candidate of Psychological Sciences, Senior Research Scientist 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.
Sergey N. Mosolov – Doctor of Medical Sciences, Professor, Honored Scientist of the Russian Federation, Head of the Department of Therapy for Mental Disorders, 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, Russian Medical Academy of Continuous Professional Education of the Russian Ministry of Health, Member of the Executive Committee of the Russian Society of Psychiatrists.
Gennady N. Ponomarenko – Corresponding Member of the Russian Academy of Sciences, 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 and Social Evaluation and Rehabilitation of the Ministry of Labor of Russia, Head of the Department of Physical and Rehabilitation Medicine, North-Western State Medical University named after I.I. Mechnikov of the Russian Ministry of Health, Member of the Interregional Society of Physical and Rehabilitation Medicine.
Dmitry S. Radionov – Junior Research Scientist at the Department for the Treatment 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 Society of Psychiatrists.
Aiperi K. Khasanova – Assistant at the Department of Psychiatry, RMAPO, Member of the Russian Society of Psychiatrists.
Conflict of interest: none declared
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience for these clinical guidelines:
Psychiatrists
Psychotherapists
Medical psychologists
General practitioners (family physicians)
Table 1. Scale for assessing levels of reliable evidence (LRE) for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of reference-controlled studies or systematic review of randomized controlled trials (RCTs) using meta-analysis |
2 | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table 2. Scale for assessing the levels of evidence (LE) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)
LoE | Definition |
|---|---|
1 | Systematic review of RCTs with meta-analysis |
2 | Individual RCTs and systematic reviews of studies of any design except RCTs, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table 3. Scale for grading grades of recommendation (GR) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines.
The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.
Appendix A3. Reference Materials
1. Order of the Ministry of Health of Russia dated December 20, 2012 No. 1225n "On approval of the standard of primary health care for neurotic, stress-related and somatoform disorders, generalized anxiety disorder in outpatient settings of a psychoneurological dispensary (dispensary department, office)".
2. Order of the Ministry of Health of Russia dated December 20, 2012 No. 1229n "On approval of the standard of specialized medical care for neurotic, stress-related and somatoform disorders, generalized anxiety disorder".
3. Recommended drug doses for GAD treatment
Table 1.
Drug | Recommended dose (mg) |
|---|---|
Selective serotonin reuptake inhibitors | |
Paroxetine ** | 20-40 [33,34,36] |
Escitalopram | 10-20 [33,34,36] |
#Sertraline** | 50-200 [47] |
#Citalopram | 20-30 [47] |
#Fluvoxamine | 150-300 [176,177] |
#Fluoxetine** | 20 [112] |
Other antidepressant classes | |
#Venlafaxine | 75-225 [47,109] |
Duloxetine | 30-120 [47,106] |
#Clomipramine** | 50-250 [45,109] |
#Imipramine** | 50-200 [108] |
#Mirtazapine | 15-45 [115] |
Agomelatine | 25-50[79] |
#Trazodone | 150-400 [108] |
#Vortioxetine | 2,5-10 [81,135,136] |
Benzodiazepine derivatives | |
Alprazolam | 0,5-2[148,149,150] |
Diazepam** | 5-20 [151,152,153,154] |
Bromdihydrochlorophenylbenzodiazepine** | 1-3 [33] |
Anxiolytics | |
Hydroxyzine** | 50-100 [33,74] |
Buspirone | 15-60 [73,75] |
Marituperdin | 40 [169,170] |
#Etifoxine | 150-200 [121,122] |
Fabomotizole | 30-60 [118,119] |
Antipsychotics | |
#Aripiprazole | 7,5-30 [114] |
#Quetiapine**1 | 50-300[110] |
#Risperidone ** | 0,5-1,5 [111] |
#Olanzapine**2 | 2,5-20 [112] |
#Sulpiride** | 50-400 [65,69,134] |
#Chlorprothixene | 15-100 [65,70,71] |
Alimemazine as part of combination therapy | 20-80 [68,72,235] |
Antiepileptic drugs | |
Pregabalin** | 150-600 [33,34,222,223] |
#Valproic acid** | 1500 [172] |
Note. 1 – doses for #Quetiapine XR**; 2 – in combination with #fluoxetine** 3 – in combination with #olanzapine** | |
4. Comparative clinical efficacy and tolerability of psychopharmacotherapy in GAD
Note.
+ – weak effect;
++ – moderate effect;
+++ – pronounced effect;
++++ – maximal effect
Appendix B. Physician Action Algorithms
Management algorithms for patients with generalized anxiety disorder
Diagnostic algorithm for generalized anxiety disorder
Appendix B1. Algorithm of psychopharmacotherapy for generalized anxiety disorder
Notes
§ The effect of antidepressants often develops more slowly and is progressive in nature; therefore, in cases of partial response, it is sometimes advisable to continue treatment for up to 12 weeks.
§§ Benzodiazepine derivatives and pregabalin should be used in patients with no history of substance abuse. In cases of severe anxiety, combining antidepressants with benzodiazepine derivatives is permissible during the first course of therapy.
Appendix B2. Algorithm for the prevention and management of antidepressant withdrawal syndrome (AWS)
Note. AD – antidepressant, SSRIs – selective serotonin reuptake inhibitors, SNRIs – serotonin-norepinephrine reuptake inhibitors, AWS – antidepressant withdrawal syndrome
If a decision is made to discontinue long-term antidepressant therapy, a gradual taper of the antidepressant dose is strongly preferred. When there is a high risk of antidepressant withdrawal syndrome (AWS), the slowest possible taper is desirable; however, there are no universal guidelines regarding the duration of the tapering period or the minimum dose to which the antidepressant should be reduced prior to cessation. If AWS 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 AWS, symptomatic therapy is required. In cases of severe symptoms upon antidepressant discontinuation or significant dose reduction, the following options are available, which are equivalent in terms of efficacy and have no predetermined sequence of use: 1) resume the antidepressant at the minimum effective dose, or at the dose where withdrawal symptoms were absent, followed by a more fractional and gradual titration; 2) when discontinuing an SSRI or SNRI, one may switch to fluoxetine, discontinue the original antidepressant after several weeks of fluoxetine treatment, and subsequently taper fluoxetine gradually; when discontinuing antidepressants from other classes, one may switch to a pharmacologically similar antidepressant with a longer half-life and subsequently taper both antidepressants gradually, similar to the switch to fluoxetine.
Appendix C. Patient Information
What are anxiety disorders?
Anxiety disorders are a group of nervous system conditions whose primary manifestation is a persistent feeling of anxiety arising for trivial reasons or in the absence of any cause. One of these is GAD (Generalized Anxiety Disorder)
What are the main symptoms of anxiety disorders?
Unfounded feelings of anxiety, shortness of breath, dizziness, fear of death or impending disaster, chest or abdominal pain, sensation of a "lump in the throat," etc. GAD is characterized by a constant sense of anxiety and tension unrelated to life circumstances, hardships, difficult life situations, or stress.
Diagnosis of anxiety disorders.
Typically, an anxiety disorder is diagnosed after ruling out all medical conditions that may present with similar symptoms. The diagnosis and treatment of anxiety disorders and panic attacks are managed by a psychotherapist or psychiatrist.
A preliminary diagnosis can be made by a general practitioner or neurologist.
Treatment of anxiety states.
Treatment for anxiety disorders includes psychotherapy and the prescription of medications that reduce anxiety.
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.
Pharmacological treatment of anxiety disorders involves the use of various agents targeting anxiety. Medications that reduce anxiety are called anxiolytics (sedatives). Medical treatment—prescription, therapy adjustment, and discontinuation of drugs—is carried out exclusively by a specialist physician.
Additional Information
In addition to professional help, an individual's lifestyle plays a significant role in the treatment and prevention of GAD.
First and foremost, to achieve a positive treatment outcome, it is crucial to adhere to the chosen treatment plan. This can be challenging, but ultimately therapy will help return you to a normal life free from constant anxiety.
It is recommended not to abuse alcohol, large amounts of caffeine, nicotine, and psychoactive substances. All of the above contribute to elevated levels of anxiety.
Relaxation techniques (yoga, deep breathing, muscle relaxation, and others) help many patients. Physical activity can also help improve mood and enhance the positive effects of treatment.
Maintaining a daily routine, specifically normalizing nocturnal sleep, has a positive impact on mental well-being and helps reduce the likelihood of developing chronic anxiety.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
Appendix G1. Hamilton Anxiety Rating Scale (HARS)
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 physicians, psychiatrists, etc. The scale is completed during a semi-structured interview, during which the clinician collects anamnestic data and observes the patient's behavior and other non-verbal manifestations of the psychopathological phenomena under study. The scale should not be handed to the patient, nor should direct questions from the scale be read to them.
HARS consists of 14 items, each scored on a Likert scale. 13 items relate to manifestations of anxiety in daily life, and the 14th relates to observed anxiety during the examination. Response options are standardized: each item can contribute an equal number of points to the total scale value, eliminating the need to spell out separate response options for each item, which greatly simplifies scale comprehension and scoring.
The assessment takes 20–30 minutes, during which the examiner listens to the subject's response to the question topic and rates it on a five-point scale.
Content (template):
1. Anxious mood (worries, anticipation of the worst, fearful anticipation, irritability).
0. Absent.
1. Mild.
2. Moderate.
3. Severe.
4. Very severe.
2. Tension (feelings of tension, fatigability, startle response, moving to tears easily, trembling, feelings of restlessness, inability to relax).
0. Absent.
1. Mild.
2. Moderate.
3. Severe.
4. Very severe.
3. Fears (of dark, of strangers, of animals, of traffic, of crowds, of being left alone).
0. Absent.
1. Mild.
2. Moderate.
3. Severe.
4. Very severe.
4. Insomnia (difficulty falling asleep, broken sleep, unsatisfying sleep and fatigue on waking, dreams, nightmares).
0. Absent.
1. Mild.
2. Moderate.
3. Severe.
4. Very severe.
5. Intellectual (difficulty in concentration, poor memory).
0. Absent.
1. Mild.
2. Moderate.
3. Severe.
4. Very severe.
6. Depressed mood (loss of interest, lack of pleasure in hobbies, depression, early waking, diurnal mood swings).
0. Absent.
1. Mild.
2. Moderate.
3. Severe.
4. Very severe.
7. Somatic (muscular) symptoms (pains and aches, twitching, stiffness, myoclonic jerks, teeth grinding, unsteadiness of voice, increased muscular tone).
0. Absent.
1. Mild.
2. Moderate.
3. Severe.
4. Very severe.
8. Somatic (sensory) symptoms (tinnitus, blurring of vision, hot and cold flushes, feelings of weakness, pricking sensations).
0. Absent.
1. Mild.
2. Moderate.
3. Severe.
4. Very severe.
9. Cardiovascular symptoms (tachycardia, palpitations, pain in chest, throbbing vessels, fainting feelings, sighing, dyspnea).
0. Absent.
1. Mild.
2. Moderate.
3. Severe.
4. Very severe.
10. Respiratory symptoms (pressure or constriction in chest, choking feelings, sighing, dyspnea).
0. Absent.
1. Mild.
2. Moderate.
3. Severe.
4. Very severe.
11. Gastrointestinal symptoms (difficulty in swallowing, wind, abdominal pain, burning sensations, fullness, nausea, vomiting, borborygmi, looseness of bowels, weight loss, constipation).
0. Absent.
1. Mild.
2. Moderate.
3. Severe.
4. Very severe.
12. Genitourinary symptoms (micturition frequency, urgency, amenorrhea, menorrhagia, development of frigidity, premature ejaculation, loss of libido, impotence).
0. Absent.
1. Mild.
2. Moderate.
3. Severe.
4. Very severe.
13. Autonomic symptoms (dry mouth, flushing, skin pallor, hyperhidrosis, tension headaches).
0. Absent.
1. Mild.
2. Moderate.
3. Severe.
4. Very severe.
14. Behavior during examination (fidgeting, restless gestures or gait, hand tremor, frowning, tense facial expression, sighing or tachypnea, facial pallor, frequent swallowing, etc.).
0. Absent.
1. Mild.
2. Moderate.
3. Severe.
4. Very severe.
Key (interpretation)
To obtain a total score reflecting the severity of the anxiety disorder, the scores for all items must be summed.
In addition, the first six items can be evaluated separately as psychological anxiety manifestations, and the remaining eight as somatic anxiety manifestations.
0–7 points – absence of anxiety.
8–17 points – presence of anxiety disorder symptoms.
18–24 points – moderate severity of anxiety disorder.
25–56 points – severe anxiety disorder.
Thus, the total score in individuals without anxiety is close to zero. The maximum possible total score of 56 reflects the extreme severity of the anxiety state.
Additionally, based on the severity of individual anxiety symptoms, the leading symptomatology is evaluated:
Anxious mood – apprehension, anticipation of the worst, anxious fears, irritability.
Tension – feeling of tension, startling, easily provoked crying, tremor, feeling of restlessness, inability to relax.
Fears – fear of the dark, strangers, animals, transport, crowds, fear of being alone.
Insomnia – difficulty falling asleep, broken sleep, unrefreshing sleep with a feeling of fatigue and weakness upon awakening, nightmares.
Intellectual impairments – difficulty concentrating, memory impairment.
Depressive mood – loss of usual interests, loss of pleasure from hobbies, low mood, early awakening, diurnal fluctuations in condition.
Somatic symptoms (muscular) – pain, muscle twitching, tension, myoclonic jerks, teeth grinding, breaking voice, increased muscle tone.
Somatic symptoms (sensory) – tinnitus, blurred vision, hot or cold flashes, feeling of weakness, tingling sensation.
Cardiovascular symptoms – tachycardia, palpitations, chest pain, vascular pulsation, feeling of weakness, frequent sighing, dyspnea.
Respiratory symptoms – feeling of chest pressure or tightness, smothering sensation, frequent sighing, dyspnea.
Gastrointestinal symptoms – difficulty swallowing, flatulence, abdominal pain, feeling of gastric fullness, nausea, vomiting, abdominal rumbling, diarrhea, weight loss, constipation.
Genitourinary symptoms – urinary frequency, strong urinary urgency, amenorrhea, menorrhagia, frigidity, premature ejaculation, loss of libido, impotence.
Autonomic symptoms – dry mouth, flushing, skin pallor, hyperhidrosis, tension headaches.
Behavior during examination – fidgeting, restless gestures or gait, hand tremor, frowning, tense facial expression, sighing or tachypnea, facial pallor, frequent swallowing, etc.
Appendix G2. GAD-7 screening questionnaire
Russian title: GAD-7 Screening Questionnaire
Original title: GAD-7
Source: Spitzer R.L. et al. A brief measure for assessing generalized anxiety disorder. Arch Intern Med 2006;166(10):1092-7
Zolotareva A.A. Adaptation of the Russian-language version of the Generalized Anxiety Disorder-7 scale // Counseling Psychology and Psychotherapy. 2023. Vol. 31, No. 4, pp. 31–46. DOI: 10.17759/cpp.2023310402
Type (underline):
- scale
- index
- questionnaire
- other (specify):
Purpose:
Conducting a screening survey to determine the level of anxiety and assess the probability of GAD
Content (template):
Over the last 2 weeks, how often have you been bothered by the following problems? | Never | Several days | More than half the days | Nearly every day |
|---|---|---|---|---|
1. Increased nervous excitability, anxiety, and irritability | 0 | 1 | 2 | 3 |
2. Inability to control worrying | 0 | 1 | 2 | 3 |
3. Excessive worrying about various things | 0 | 1 | 2 | 3 |
4. Inability to relax | 0 | 1 | 2 | 3 |
5. Extreme restlessness: "unable to sit still" | 0 | 1 | 2 | 3 |
6. Easily becoming anxious or irritable | 0 | 1 | 2 | 3 |
7. Fear that something awful might happen | 0 | 1 | 2 | 3 |
Key (interpretation)
The total score across all 7 questions is evaluated.
Total score | Anxiety level |
|---|---|
0-4 | Minimal |
5-9 | Moderate |
10-14 | Neuter |
15-21 | High |
Notes: This tool is for screening purposes and requires further clinical evaluation to establish a diagnosis of generalized anxiety disorder.
Appendix G3. Symptom Checklist-90-Revised (SCL-90-R)
Russian title: Symptom Checklist
Original title: Symptom Check List-90-Revised – SCL-90-R (Derogatis L.R. et al., 1974). Derogatis L.R. The SCL-90-R // Clinical Psychometric Research. – Baltimore. – 1975.
Source (official developer website, validation publication): Adaptation of the method by N.V. Tarabrina, Institute of Psychology of the Russian Academy of Sciences, Laboratory of Psychology of Post-Traumatic Stress and Psychotherapy, 2001. Tarabrina N.V. Praktikum po psikhologii posttravmaticheskogo stressa. – St. Petersburg: Piter, 2001. – 272 p.
Type (underline):
- rating scale
- index
- questionnaire
- other (specify):
Purpose: SCL-90-R is a self-report scale designed to determine the current psychological symptom status. The SCL-90-R scale is a clinical test and screening method intended to assess psychological symptom patterns in psychiatric patients and healthy individuals.
The SCL-90-R questionnaire consists of 90 items, each rated on a 5-point distress rating scale ranging from "not at all" to "extremely". These items measure the severity of 9 symptom dimensions that form the basis of most behavioral symptoms in psychiatric patients. Each dimension includes at least 6 items. The reliability of rating scales is proportional to the number of scale items (within certain limits). This has been confirmed by both psychometric and information theory. A small number of SCL-90-R items are not included in the 9 primary dimensions and are grouped separately as additional items.
Content (template):
Instructions. Below is a list of problems and complaints that people sometimes experience. Please read each item carefully. Circle the number of the answer that best describes the degree of your distress or anxiety caused by each problem during the past week, up to and including today. Circle only one number for each item (so that the digit inside the circle is visible), without skipping any items. If you wish to change your response, cross out your original mark.
Full Name________________________________________________ Date _____________
How much were you distressed by: | Not at all none | A little bit | Moderately | Severely | Quite a bit Extremely |
|---|---|---|---|---|---|
1. Headaches | 0 | 1 | 2 | 3 | 4 |
2. Nervousness or inner trembling | 0 | 1 | 2 | 3 | 4 |
3. Repetitive, intrusive, unpleasant thoughts | 0 | 1 | 2 | 3 | 4 |
4. Weakness or dizziness | 0 | 1 | 2 | 3 | 4 |
5. Loss of sexual desire or pleasure | 0 | 1 | 2 | 3 | 4 |
6. Feeling resentful toward others | 0 | 1 | 2 | 3 | 4 |
7. The feeling that someone else can control your thoughts | 0 | 1 | 2 | 3 | 4 |
8. The feeling that others are to blame for most of your troubles | 0 | 1 | 2 | 3 | 4 |
9. Memory problems | 0 | 1 | 2 | 3 | 4 |
10. Carelessness or untidiness on your part | 0 | 1 | 2 | 3 | 4 |
11. Easily feeling annoyed or irritated | 0 | 1 | 2 | 3 | 4 |
12. Pains in the heart or chest | 0 | 1 | 2 | 3 | 4 |
13. Feeling afraid in open spaces or on the street | 0 | 1 | 2 | 3 | 4 |
14. Lack of energy or slowed down | 0 | 1 | 2 | 3 | 4 |
15. Thoughts of ending your life | 0 | 1 | 2 | 3 | 4 |
16. Hearing voices that other people do not hear | 0 | 1 | 2 | 3 | 4 |
17. Trembling | 0 | 1 | 2 | 3 | 4 |
18. The feeling that most people cannot be trusted | 0 | 1 | 2 | 3 | 4 |
19. Poor appetite | 0 | 1 | 2 | 3 | 4 |
20. Crying easily | 0 | 1 | 2 | 3 | 4 |
21. Shyness or awkwardness with members of the opposite sex | 0 | 1 | 2 | 3 | 4 |
22. The feeling of being trapped or caught | 0 | 1 | 2 | 3 | 4 |
23. Sudden or causeless fear | 0 | 1 | 2 | 3 | 4 |
24. Outbursts of anger you could not control | 0 | 1 | 2 | 3 | 4 |
25. Fear of leaving the house alone | 0 | 1 | 2 | 3 | 4 |
26. The feeling that you are largely to blame | 0 | 1 | 2 | 3 | 4 |
27. Lower back pain | 0 | 1 | 2 | 3 | 4 |
28. The feeling that something is blocking you from doing things | 0 | 1 | 2 | 3 | 4 |
29. Feeling lonely | 0 | 1 | 2 | 3 | 4 |
30. Low mood, feeling blue | 0 | 1 | 2 | 3 | 4 |
31. Excessive worry about various things | 0 | 1 | 2 | 3 | 4 |
32. Lack of interest in anything | 0 | 1 | 2 | 3 | 4 |
33. Feeling afraid | 0 | 1 | 2 | 3 | 4 |
34. Having your feelings easily hurt | 0 | 1 | 2 | 3 | 4 |
35. The feeling that others are reading your thoughts | 0 | 1 | 2 | 3 | 4 |
36. The feeling that others do not understand you or sympathize with you | 0 | 1 | 2 | 3 | 4 |
37. The feeling that people are unfriendly or dislike you | 0 | 1 | 2 | 3 | 4 |
38. The need to do things very slowly to avoid making mistakes | 0 | 1 | 2 | 3 | 4 |
39. Pounding or racing heart | 0 | 1 | 2 | 3 | 4 |
40. Nausea or upset stomach | 0 | 1 | 2 | 3 | 4 |
41. The feeling that you are inferior to others | 0 | 1 | 2 | 3 | 4 |
42. Muscle pain | 0 | 1 | 2 | 3 | 4 |
43. The feeling that others are watching you or talking about you | 0 | 1 | 2 | 3 | 4 |
44. Difficulty falling asleep | 0 | 1 | 2 | 3 | 4 |
45. The need to check and double-check what you do | 0 | 1 | 2 | 3 | 4 |
46. Difficulty making decisions | 0 | 1 | 2 | 3 | 4 |
47. Fear of riding in buses | 0 | 1 | 2 | 3 | 4 |
48. Difficulty breathing | 0 | 1 | 2 | 3 | 4 |
49. Hot or cold flashes | 0 | 1 | 2 | 3 | 4 |
50. The need to avoid certain places or activities because they frighten you | 0 | 1 | 2 | 3 | 4 |
51. Losing your train of thought easily | 0 | 1 | 2 | 3 | 4 |
52. Numbness or tingling in various parts of the body | 0 | 1 | 2 | 3 | 4 |
53. A lump in the throat | 0 | 1 | 2 | 3 | 4 |
54. The feeling that the future is hopeless | 0 | 1 | 2 | 3 | 4 |
55. Difficulty concentrating | 0 | 1 | 2 | 3 | 4 |
56. Feeling weak in various parts of the body | 0 | 1 | 2 | 3 | 4 |
57. Feeling tense or keyed up | 0 | 1 | 2 | 3 | 4 |
58. Heaviness in the limbs | 0 | 1 | 2 | 3 | 4 |
59. Thoughts of death | 0 | 1 | 2 | 3 | 4 |
60. Overeating | 0 | 1 | 2 | 3 | 4 |
61. Feeling self-conscious when people are watching you | 0 | 1 | 2 | 3 | 4 |
62. The experience of having thoughts that are not your own | 0 | 1 | 2 | 3 | 4 |
63. Urges to inflict physical injury or harm upon someone | 0 | 1 | 2 | 3 | 4 |
64. Awakening in the early morning hours | 0 | 1 | 2 | 3 | 4 |
65. The need to repeat actions: touching, washing, counting | 0 | 1 | 2 | 3 | 4 |
66. Restless and disturbed sleep | 0 | 1 | 2 | 3 | 4 |
67. Urges to break or smash things | 0 | 1 | 2 | 3 | 4 |
68. The presence of ideas or beliefs that others do not share | 0 | 1 | 2 | 3 | 4 |
69. Excessive shyness when interacting with others | 0 | 1 | 2 | 3 | 4 |
70. Feeling uneasy in crowded places (stores, movie theaters) | 0 | 1 | 2 | 3 | 4 |
71. The feeling that everything you do requires a great deal of effort | 0 | 1 | 2 | 3 | 4 |
72. Attacks of terror or panic | 0 | 1 | 2 | 3 | 4 |
73. Feeling uneasy when eating or drinking in public | 0 | 1 | 2 | 3 | 4 |
74. Frequently entering into arguments | 0 | 1 | 2 | 3 | 4 |
75. Nervousness when left alone | 0 | 1 | 2 | 3 | 4 |
76. The feeling that others underestimate your achievements | 0 | 1 | 2 | 3 | 4 |
77. Feeling lonely even when you are with other people | 0 | 1 | 2 | 3 | 4 |
78. Such intense restlessness that you could not sit still | 0 | 1 | 2 | 3 | 4 |
79. Feelings of worthlessness | 0 | 1 | 2 | 3 | 4 |
80. The feeling that something bad is going to happen to you | 0 | 1 | 2 | 3 | 4 |
81. Shouting or throwing things | 0 | 1 | 2 | 3 | 4 |
82. Fear of fainting in public | 0 | 1 | 2 | 3 | 4 |
83. The feeling that people would take advantage of your trust if you let them | 0 | 1 | 2 | 3 | 4 |
84. Distressing sexual thoughts | 0 | 1 | 2 | 3 | 4 |
85. The thought that you should be punished for your sins | 0 | 1 | 2 | 3 | 4 |
86. Nightmare thoughts or visions | 0 | 1 | 2 | 3 | 4 |
87. Thoughts that something is wrong with your body | 0 | 1 | 2 | 3 | 4 |
88. Not feeling close to anyone | 0 | 1 | 2 | 3 | 4 |
89. Feelings of guilt | 0 | 1 | 2 | 3 | 4 |
90. Thoughts that something is wrong with your mind | 0 | 1 | 2 | 3 | 4 |
Key (interpretation):
Key.
№ | Scales | Items | Number of items |
|---|---|---|---|
1 | SOM Somatization | 1 4 12 27 40 42 48 49 52 53 56 58 | 12 |
2 | O-C Obsessive-Compulsive | 3 9 10 28 38 45 46 51 55 65 | 10 |
3 | INT Interpersonal Sensitivity | 6 21 34 36 37 41 61 69 73 | 9 |
4 | DEP Depression | 14 15 20 22 26 29 30 31 32 54 56 71 79 | 13 |
5 | ANX Anxiety | 2 17 23 33 39 57 72 78 80 86 | 10 |
6 | HOS Hostility | 11 24 63 67 74 81 | 6 |
7 | PHOB Phobic Anxiety | 13 25 47 50 70 75 82 | 7 |
8 | PAR Paranoid Ideation | 8 18 43 68 76 83 | 6 |
9 | PSY Psychoticism | 7 16 35 62 77 84 85 87 88 90 | 10 |
10 | Dopoln. Additional items | 19 44 59 60 64 66 89 | 7 |
Data Processing
1. Scale scores – 9 indicators. Divide the sum of scores for each scale by the number of items in that scale. For example, the sum of scores for the 1st scale is divided by 12, for the 2nd by 10, etc.
2. Total score – GSI (Global Severity Index). Divide the grand total of all scores by 90 (the number of items in the questionnaire).
3. PSI (Positive Symptom Index). The number of items scored from 1 to 4 is calculated.
4. PSDI (Positive Symptom Distress Index). Multiply the GSI index by 90 and divide by the PSI index.
Summary Table
№ | Scales | Normal | Patients | ||||
|---|---|---|---|---|---|---|---|
Russia | USA | ||||||
Russia | USA | Neurosis before treatment | Neurosis after treatment | Outpatient psychiatry | Inpatient psychiatry | ||
1 | SOM | 0,44±0,03 | 0,36 | 1,28±0,08 | 0,70 | 0,87 | 0,99 |
2 | O-C | 0,75±0,04 | 0,39 | 1,45±0,08 | 0,77 | 1,47 | 1,45 |
3 | INT | 0,66±0,03 | 0,29 | 1,40±0,10 | 0,84 | 1,41 | 1,32 |
4 | DEP | 0,62±0,04 | 0,36 | 1,56±0,08 | 0,73 | 1,79 | 1,74 |
5 | ANX | 0,47±0,03 | 0,30 | 1,66±0,10 | 0,78 | 1,47 | 1,48 |
6 | HOS | 0,60±0,04 | 0,30 | 1,03±0,07 | 0,58 | 1,10 | 0,94 |
7 | PHOB | 0,18±0,02 | 0,13 | 1,13±0,10 | 0,74 | 0,74 | 0,96 |
8 | PAR | 0,54±0,04 | 0,34 | 0,86±0,08 | 0,63 | 1,16 | 1,26 |
9 | PSY | 0,30±0,03 | 0,14 | 0,82±0,07 | 0,41 | 0,94 | 1,11 |
10 | Dopoln. | 0,49±0,03 | 1,29±0,08 | 0,62 | |||
11 | GSI | 0,51±0,02 | 0,31 | 1,29±0,06 | 0,69 | 1,26 | 1,30 |
12 | PSI | 21,39±2,02 | 57,04±3,10 | ||||
13 | PDSI | 1,17±0,05 | 2,15±0,06 | ||||
Interpretation
1. Somatization. The items included in this scale reflect distress arising from the perception of bodily dysfunctions. The parameter includes complaints regarding the cardiovascular, gastrointestinal, respiratory, and other systems. When an organic basis for the complaints is ruled out, various somatoform disorders and anxiety equivalents are registered.
2. Obsessive-Compulsive. The core of this scale is the clinical syndrome of the same name. It includes items indicating the repetitive and unwanted nature of certain phenomena, as well as the presence of more general cognitive difficulties.
3. Interpersonal Sensitivity. The symptoms forming the basis of this scale reflect feelings of personal inadequacy and inferiority in social contacts. The scale includes items reflecting self-deprecation, feelings of awkwardness, and pronounced discomfort during interpersonal interaction. It reflects a tendency toward self-reflection and low self-esteem.
4. Depression. The items belonging to the depression scale reflect a wide range of circumstances associated with the clinical depressive syndrome. Complaints regarding a loss of interest in activities, lack of motivation, and loss of vital energy are included. The scale also includes items related to suicidal ideation, feelings of hopelessness, uselessness, and other somatic and cognitive characteristics of depression.
5. Anxiety. This scale encompasses a group of symptoms and reactions that are typically clinically associated with overt (manifest) anxiety, reflecting a feeling of oppressive, causeless internal restlessness. The basis of this scale consists of complaints of nervousness, impatience, and internal tension combined with somatic and motor manifestations.
6. Anger-Hostility. This parameter is formed from three categories of hostile behavior: thoughts, feelings, and actions.
7. Phobic Anxiety. Complaints included in this scale reflect fears associated with travel, open spaces, public places, transportation, and phobic reactions of a social nature.
8. Paranoid Ideation. In creating this scale, L.R. Derogatis et al. proceeded from the premise that paranoid phenomena are best understood when perceived as a mode of thinking. Traits of paranoid thinking of primary importance, within the limitations imposed by the questionnaire, were included in the scale. These are primarily projective thinking, hostility, suspiciousness, and ideas of reference.
9. Psychoticism. This scale is based on the following symptoms: auditory hallucinations, thought broadcasting, external control of thoughts, and intrusion of thoughts from outside. Along with these items, the questionnaire presents other indirect signs of psychotic behavior, as well as symptoms indicating a schizoid lifestyle.
Appendix G4. Integrative Anxiety Test (IAT)
Russian title: Integrative Anxiety Test – ITT
Original title: Integrative Anxiety Test – ITT
Source: Developed at the Laboratory of Clinical Psychology of the V.M. Bekhterev Institute (Bizyuk A.P., Wasserman L.I., Iovlev B.V., 1997). Bizyuk A.P. Application of the Integrative Anxiety Test (ITT) // Methodological Recommendations / A.P. Bizyuk, L.I. Wasserman, B.V. Iovlev. – St. Petersburg: Publishing House of the V.M. Bekhterev NIPNI, 2003. – 23 p.
Type (underline):
- rating scale
- index
- questionnaire
- other (specify):
Purpose: The Integrative Anxiety Test (ITT) methodology is a medical (medical-psychological) technology, serving as an original express psycho-diagnostic tool for differentiated assessment and qualitative qualification across 5 factors (subscales) of anxiety as a nonspecific, complex-genesis affective regulator of personality behavior, and anxiety as a personality-typological characteristic. The analysis of the adaptogenic and pathogenic role of the "anxiety – trait anxiety" tandem allows for clarifying therapy mechanisms and assessing the effectiveness of treating mental maladaptation of various origins.
To assess the significance level for respondents of 15 statements across the self-assessment of state anxiety (ST-S) and self-assessment of trait anxiety (ST-L) scales, the traditional 4-point rating system of subjective personal scaling is used: 0 – absence of the given trait, two others are associated with the presence of weakly and moderately expressed traits (scores 1 and 2), and the last – as an extreme degree of severity from the respondent's perspective – 3 points. Thus, the maximum number of raw scores that can be obtained on both ITT scales is 45.
Content (template):
Registration form of the trait anxiety scale (ST-L SCALE)
Full Name ______________________________________________
Age ___________________
Examination Date ____________
Examination Place _______________________________
Below are several statements concerning your emotional state. For each of them, you need to decide – HOW OFTEN over the recent period (for example, over the past year) you have experienced it. Depending on this, place a "+" sign in one of the four columns.
Almost never 0 | Rarely 1 | Frequent 2 | Almost all the time 3 | |
|---|---|---|---|---|
1. I felt tense | ||||
2. I got upset | ||||
3. I worried about the future | ||||
4. I was nervous | ||||
5. I was preoccupied | ||||
6. I was agitated | ||||
7. I felt an inexplicable threat | ||||
8. I tired quickly | ||||
9. I lacked self-confidence | ||||
10. I avoided any conflicts | ||||
11. I easily became confused | ||||
12. I felt useless | ||||
13. I slept poorly | ||||
14. I felt exhausted | ||||
15. I was emotionally sensitive |
Raw scores | Stanines | |
|---|---|---|
Total score |
ED | AST | PHOB | OP | SZ | |
|---|---|---|---|---|---|
Raw scores | |||||
Stanines |
Registration form of the state anxiety scale (ST-S SCALE)
Full Name __________________________________________________ Age_______________
Examination Date ____________ Examination Place _______________________________
Below are several statements concerning your emotional state. For each of them, you need to decide – to what extent this state is expressed RIGHT NOW, AT THIS MOMENT, TODAY. Depending on this, place a "+" sign in one of the four columns.
Not at all 0 | Slightly expressed 1 | Pronounced 2 | Very expressed 3 | |
|---|---|---|---|---|
I am tense | ||||
I am upset | ||||
I am worried about the future | ||||
I am nervous | ||||
I am preoccupied | ||||
I am agitated | ||||
I feel an inexplicable threat | ||||
I tire faster than usual | ||||
I lack self-confidence | ||||
I avoid any conflicts | ||||
I feel confused | ||||
I feel useless | ||||
I slept restlessly | ||||
I feel tired | ||||
I am emotionally sensitive |
Raw scores | Stanines | |
|---|---|---|
Total score |
ED | AST | PHOB | OP | SZ | |
|---|---|---|---|---|---|
Raw scores | |||||
Stanines |
Key (interpretation)
Key
Conversion table to stanines for the general personal anxiety score and the general situational anxiety score
Stanines | Raw scores | |
|---|---|---|
Adults and adolescent males | Adolescent females | |
1 | 6 or less | 6 or less |
2 | 7-8 | 7-8 |
3 | 9 | 9-10 |
4 | 10-11 | 11-12 |
5 | 12-14 | 13-16 |
6 | 15-18 | 17-21 |
7 | 19-22 | 22-25 |
8 | 23-26 | 26-30 |
9 | 27 or more | 31 or more |
Table for calculating auxiliary scale scores
ED | AST | PHOB | OP | SZ | |
|---|---|---|---|---|---|
1 | 74 49 25 | ||||
2 | 73 49 24 | ||||
3 | 110 74 37 | ||||
4 | 80 53 27 | ||||
5 | 98 65 32 | ||||
6 | 73 49 24 | ||||
7 | 111 74 37 | ||||
8 | 91 61 30 | ||||
9 | 85 56 28 | ||||
10 | 171 114 57 | ||||
11 | 129 86 43 | ||||
12 | 87 58 29 | ||||
13 | 122 81 41 | ||||
14 | 87 58 29 | ||||
15 | 92 61 31 |
Conversion of auxiliary scale scores to stanines for adults and adolescent males
Stanines | Sums of diagnostic coefficients | ||||
|---|---|---|---|---|---|
ED | AST | PHOB | OP | SZ | |
1 | 34 or less | 26 or less | 13 or less | 44 or less | 50 or less |
2 | 35-48 | 27-36 | 14-19 | 45-62 | 51-70 |
3 | 49-62 | 37-47 | 20-24 | 63-80 | 71-90 |
4 | 63-76 | 48-57 | 25-29 | 81-97 | 91-110 |
5 | 77-100 | 58-82 | 30-54 | 98-122 | 111-135 |
6 | 101-137 | 83-122 | 55-99 | 123-155 | 136-165 |
7 | 138-173 | 123-161 | 100-144 | 156-187 | 166-195 |
8 | 174-209 | 162-201 | 145-188 | 188-219 | 196-225 |
9 | 210 or more | 202 or more | 189 or more | 220 or more | 226 or more |
Conversion of auxiliary scale scores to stanines for adolescent females
Stanines | Sums of diagnostic coefficients | ||||
|---|---|---|---|---|---|
ED | AST | PHOB | OP | SZ | |
1 | 42 or less | 31 or less | 16 or less | 53 or less | 60 or less |
2 | 43-58 | 32-44 | 17-23 | 54-75 | 61-85 |
3 | 59-75 | 45-57 | 24-29 | 76-97 | 86-109 |
4 | 76-92 | 58-70 | 30-36 | 98-118 | 110-134 |
5 | 93-117 | 71-95 | 37-61 | 119-143 | 135-159 |
6 | 118-150 | 96-132 | 62-104 | 144-172 | 160-184 |
7 | 151-183 | 133-169 | 105-148 | 173-200 | 185-210 |
8 | 184-217 | 170-206 | 149-191 | 201-228 | 211-235 |
9 | 218 or more | 207 or more | 192 or more | 229 or more | 236 or more |
Interpretation
High scores on the "Emotional Discomfort" (ED) subscale indicate a lowered emotional background, dissatisfaction with life situation, emotional tension, and lack of emotional balance.
High scores on the "Asthenic Anxiety Component" (AAC) subscale point to asthenia, weakness, lethargy, increased mental exhaustion, and fatigue.
High scores on the "Phobic Component" (PHOB) subscale indicate that phobias (worry and fears caused by the current life situation) dominate the structure of anxiety.
High scores on the "Anxious Perspective Appraisal" (APA) subscale indicate that the structure of anxiety is dominated by fears oriented not so much toward the current state of affairs as toward the future and perspective, following the principle of "what if something happens".
The 5th subscale, "Social Defense Reactions" (SDR), is associated with the main manifestations of anxiety in the sphere of social contacts, with attempts by the subject to view the social environment as the main source of anxiety tension and self-doubt.
Appendix G5. C.D. Spielberger, Yu.L. Khanin Anxiety Assessment Scale
Russian title: C.D. Spielberger, Yu.L. Khanin Anxiety Assessment Scale
Original title: State-Trait Anxiety Inventory – STAI (Spielberger C.D., 1964).
Source: Spielberger C.D., Gorsuch R.L., Lushene R.E. Manual for the State-Trait Anxiety Inventory. // Palo Alto, CA: Consulting Psychologists Press. – 1970. Spielberger C.D. Test Anxiety Inventory: Preliminary professional manual. – Menlo Park. – 1980. Adaptation of the method by Yu.L. Khanin. Khanin Yu.L. Kratkoe rukovedstvo k shkale reaktivnoy i lichnostnoy trevozhnosti Ch.D. Spilbergera. – Leningrad. – 1976. – 18 p.
Type (underline):
- rating scale
- index
- questionnaire
- other (specify):
Purpose: The C.D. Spielberger, Yu.L. Khanin Anxiety Assessment Scale is a self-assessment scale for the level of anxiety at the given moment (reactive anxiety as a state) and personal anxiety (as a stable personality characteristic). It is used in clinical practice to determine the severity of anxiety experiences, assess the state over time, etc. Comparing the results on both subscales makes it possible to assess the individual significance of a stressful situation for the subject.
Content (template)
Instructions
Situational Anxiety Scale
Read each of the statements below carefully and cross out the number in the corresponding column on the right depending on how you feel at the present moment. Do not spend too long thinking about the questions, as there are no right or wrong answers
No. | Statement | Never | Almost never | Frequent | Almost always |
|---|---|---|---|---|---|
1 | I am calm | 1 | 2 | 3 | 4 |
2 | I feel no threat | 1 | 2 | 3 | 4 |
3 | I am tense | 1 | 2 | 3 | 4 |
4 | I feel internally constrained | 1 | 2 | 3 | 4 |
5 | I feel at ease | 1 | 2 | 3 | 4 |
6 | I am upset | 1 | 2 | 3 | 4 |
7 | I am concerned about possible failures | 1 | 2 | 3 | 4 |
8 | I feel at peace | 1 | 2 | 3 | 4 |
9 | I am anxious | 1 | 2 | 3 | 4 |
10 | I feel a sense of inner satisfaction | 1 | 2 | 3 | 4 |
11 | I am confident in myself | 1 | 2 | 3 | 4 |
12 | I am nervous | 1 | 2 | 3 | 4 |
13 | I am restless | 1 | 2 | 3 | 4 |
14 | I am keyed up | 1 | 2 | 3 | 4 |
15 | I do not feel stiffness or tension | 1 | 2 | 3 | 4 |
16 | I am pleased | 1 | 2 | 3 | 4 |
17 | I am preoccupied | 1 | 2 | 3 | 4 |
18 | I am too excited and ill at ease | 1 | 2 | 3 | 4 |
19 | I feel joyful | 1 | 2 | 3 | 4 |
20 | I feel pleasant | 1 | 2 | 3 | 4 |
Instructions
Personal Anxiety Scale
Read each of the following sentences carefully and cross out the number in the corresponding column on the right depending on how you usually feel. Do not dwell on the questions for long, as there are no right or wrong answers.
No. | Statement | Never | Almost never | Frequent | Almost always |
|---|---|---|---|---|---|
21 | I have an elevated mood | 1 | 2 | 3 | 4 |
22 | I tend to be irritable | 1 | 2 | 3 | 4 |
23 | I get upset easily | 1 | 2 | 3 | 4 |
24 | I wish I were as lucky as others | 1 | 2 | 3 | 4 |
25 | I take troubles hard and cannot forget them for a long time | 1 | 2 | 3 | 4 |
26 | I feel a surge of energy and a desire to work | 1 | 2 | 3 | 4 |
27 | I am calm, cool, and collected | 1 | 2 | 3 | 4 |
28 | I am troubled by potential difficulties | 1 | 2 | 3 | 4 |
29 | I worry too much about trifles | 1 | 2 | 3 | 4 |
30 | I am quite happy at times | 1 | 2 | 3 | 4 |
31 | I take everything to heart | 1 | 2 | 3 | 4 |
32 | I lack self-confidence | 1 | 2 | 3 | 4 |
33 | I feel defenseless | 1 | 2 | 3 | 4 |
34 | I try to avoid critical situations and difficulties | 1 | 2 | 3 | 4 |
35 | I have the blues | 1 | 2 | 3 | 4 |
36 | I am content at times | 1 | 2 | 3 | 4 |
37 | All sorts of trifles distract and worry me | 1 | 2 | 3 | 4 |
38 | Sometimes I feel like a failure | 1 | 2 | 3 | 4 |
39 | I am a balanced person | 1 | 2 | 3 | 4 |
40 | I am seized by anxiety when I think about my affairs and concerns | 1 | 2 | 3 | 4 |
Key (interpretation):
When analyzing self-assessment results, keep in mind that the total score for each subscale can range from 20 to 80 points. Moreover, the higher the total score, the higher the level of anxiety (state or trait).
The level of state anxiety is calculated using the formula:
SA = ∑dp - ∑do + 50, where:
SA is the state anxiety score;
∑dp is the sum of scores for direct questions (3, 4, 6, 7, 9, 12, 14, 15, 17, 18);
∑do is the sum of scores for reverse questions (1, 2, 5, 8, 10, 11, 13, 16, 19, 20).
To calculate the level of trait anxiety, the formula is used:
TA = ∑tp - ∑to + 35, where:
TA is the trait anxiety score;
∑tp is the sum of scores for direct questions (22, 23, 24, 25, 28, 29, 31, 32, 34, 35, 37, 38, 40);
∑to is the sum of scores for reverse questions (21, 26, 27, 30, 33, 36, 39).
Interpretation
up to 30 points – low anxiety,
31–44 points – moderate;
45 and above – high.
Individuals categorized as having high anxiety tend to perceive a threat to their self-esteem and functioning across a wide range of situations and to react with a very pronounced state of anxiety. If a psychological test reveals a high trait anxiety score in a subject, this gives grounds to assume that they will experience a state of anxiety in various situations, especially when these involve the evaluation of their competence and prestige.
Individuals with a high anxiety score should cultivate a sense of confidence and success. They need to shift the focus from external demands, categoricalness, and high task significance to a meaningful understanding of the activity and concrete planning by subtasks.
For low-anxiety individuals, conversely, it is necessary to awaken activity, emphasize the motivational components of the activity, stimulate interest, and highlight the sense of responsibility in solving specific tasks.
The state of reactive (situational) anxiety occurs when encountering a stressful situation and is characterized by subjective discomfort, tension, restlessness, and autonomic arousal. Naturally, this state varies in time and intensity depending on the impact of the stressful situation. Thus, the value of the total score on this subscale allows one to assess not only the subject's current level of anxiety, but also to determine whether they are under the influence of a stressful situation and what the intensity of this impact is.
Trait anxiety is a constitutional trait that predisposes an individual to perceive threat across a wide range of situations. With high trait anxiety, each of these situations will have a stress impact on the subject and cause pronounced anxiety. Very high trait anxiety directly correlates with the presence of a neurotic conflict, emotional and neurotic breakdowns, and psychosomatic disorders.
Appendix G6. Beck Anxiety Inventory
Russian title: Beck Anxiety Inventory
Original title: The Beck Anxiety Inventory – (BAI), (Beck A.T., 1961).
Source: Beck AT, Steer RA (1993). Beck Anxiety Inventory Manual. San Antonio: Harcourt Brace and Company.
Type (underline):
- rating scale
- index
- questionnaire
- other (specify):
Purpose: A clinical test method designed for anxiety screening and assessing its severity.
The Beck Anxiety Inventory is designed for preliminary assessment of the severity of anxiety disorders in a wide range of individuals: adolescents from 14 years of age, adults and the elderly, clinic populations, and for screening studies.
The questionnaire consists of 21 items. Each item includes one of the typical symptoms of anxiety, whether physical or psychological. Each item is rated by the respondent from 0 (not at all) to 3 (severely).
Content (template):
Instructions
This list contains the most common symptoms of anxiety. Please study each item carefully. Indicate how much you have been bothered by each of these symptoms DURING THE PAST WEEK, up to and including today, by putting a cross in the corresponding column on the right.
Sign | Not at all 0 | Mildly, but it didn't bother me much 1 | Moderately, it wasn't pleasant, but I could stand it 2 | Severely, it bothered me a lot and I could barely stand it 3 |
|---|---|---|---|---|
1. Numbness or tingling in the body | ||||
2. Feeling of heat in the body | ||||
3. Trembling in the legs | ||||
4. Inability to relax | ||||
5. Fear of the worst happening | ||||
6. Dizziness or lightheadedness | ||||
7. Rapid heartbeat | ||||
8. Unsteadiness | ||||
9. Feeling of terror | ||||
10. Nervousness | ||||
11. Trembling in the hands | ||||
12. Feeling of choking | ||||
13. Unsteady gait | ||||
14. Fear of losing control | ||||
15. Difficulty breathing | ||||
16. Fear of dying | ||||
17. Fright | ||||
18. Gastrointestinal disturbances | ||||
19. Fainting | ||||
20. Flushing of the face | ||||
21. Increased sweating (not related to heat) |
Key (interpretation)
The score is calculated by simply summing the points across all items of the BAI scale.
Scores from 0 to 9 indicate the absence of anxiety.
Scores from 10 to 21 indicate a mild level of anxiety.
Scores from 22 to 35 correspond to moderate anxiety.
Scores from 36 to 63 indicate very severe anxiety.
Appendix G7. Sheehan Anxiety Scale
Russian title: Sheehan Patient-Rated Anxiety Scale
Original title: Sheehan Patient-Rated Anxiety Scale – (SPRAS), (David V. Sheehan, 1983).
Source: Sheehan D.V., Sheehan Kr. // Int. J. Psychiat. Med, – 1983. – N 12. – P. 243-266.
Type (underline):
- rating scale
- index
- questionnaire
- other (specify):
Purpose: The Sheehan Patient-Rated Anxiety Scale is intended for screening and self-assessment of anxiety spectrum disorders in adults.
The scale was developed based on a sample of symptoms of anxiety disorders and panic attacks and includes the most common manifestations of these disorders, including somatic and autonomic manifestations of anxiety. Each item is rated on a Likert scale from 0 to 4 points.
Content (template):
Instructions.
Determine how much you have been bothered by the symptoms listed below over the past week. Mark your answer number on the answer sheet.
Over the past week (7 days), how much have you been bothered by the following complaints | Not at all 0 | A little bit 1 | Moderately 2 | Severely 3 | Extremely 4 |
|---|---|---|---|---|---|
1. Difficulty inhaling, shortness of breath, or rapid breathing | |||||
2. Feeling of suffocation or a lump in the throat | |||||
3. Heart racing, pounding, feeling as if it is about to jump out of the chest | |||||
4. Chest pain, unpleasant feeling of tightness in the chest | |||||
5. Profuse sweating (sweating profusely) | |||||
6. Weakness, dizzy spells, lightheadedness | |||||
7. "Cotton-like", "heavy" legs | |||||
8. Feeling of unsteadiness or loss of balance | |||||
9. Nausea or abdominal discomfort | |||||
10. Feeling that everything around is becoming strange, unreal, foggy, or detached | |||||
11. Feeling that everything is floating, "being out of body" | |||||
12. Tingling or numbness in various parts of the body | |||||
13. Hot or cold flashes | |||||
14. Tremor | |||||
15. Fear of death or that something terrible might happen right now | |||||
16. Fear of losing one's mind or self-control | |||||
17. Sudden anxiety attacks accompanied by three or more of the above symptoms, occurring immediately before and upon entering a situation that, in your experience, can trigger an attack | |||||
18. Sudden unexpected anxiety attacks accompanied by three or more of the above symptoms, occurring for minor reasons or without reason (i.e., when you are NOT in a situation that, in your experience, can trigger an attack) | |||||
19. Sudden unexpected attacks accompanied by only one or two of the above symptoms, occurring for minor reasons or without reason (i.e., when you are NOT in a situation that, in your experience, can trigger an attack) | |||||
20. Periods of anxiety that increase as you prepare to do something that, in your experience, can cause anxiety, and that is more intense than what most people experience in such cases | |||||
21. Avoidance of situations that frighten you | |||||
22. State of dependence on other people | |||||
23. Tension and inability to relax | |||||
24. Anxiety, "nervousness", restlessness | |||||
25. Episodes of increased sensitivity to sound, light, and touch | |||||
26. Bouts of diarrhea | |||||
27. Excessive worry about one's own health | |||||
28. Feeling tired, weak, and easily exhausted | |||||
29. Headaches or neck pain | |||||
30. Difficulty falling asleep | |||||
31. Waking up in the middle of the night or restless sleep | |||||
32. Sudden periods of depression occurring for minor reasons or no reason at all | |||||
33. Mood and emotional swings that mainly depend on what is happening around you | |||||
34. Recurrent and intrusive thoughts, ideas, impulses, or images that you find distressing, unpleasant, senseless, or repulsive | |||||
35. Repeating the same action as a ritual, such as repeatedly checking, washing, and counting when there is no need for such action |
Key (interpretation):
The total score on the scale is equal to the sum of the scores of all items. Thus, the total score can range from 0 to 140.
0–29 – absence of clinically significant anxiety,
30–79 – clinically significant anxiety,
80 and above – severe anxiety disorder, panic disorder.
According to clinical studies, scores on the Sheehan Anxiety Scale for panic disorder and agoraphobia (in neurotic disorders) range from 37 to 77 points.
Appendix G8. Minnesota Multiphasic Personality Inventory (MMPI)
Russian title: Standardized Clinical Personality Questionnaire adapted by L.N. Sobchik et al. (SMIL), 1970.
Original title: Minnesota Multiphasic Personality Inventory – (MMPI) (Hathaway & McKinley, 1943)
Source: 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 of Psychiatry and Narcology, 1971. Sobchik L.N., Standardized Multifactor Method of Personality Investigation SMIL (MMPI): Practical Guide. — Moscow: Rech, 2007. — 224 p.
Type (underline):
- rating scale
- index
- questionnaire
- other (specify):
Purpose: The MMPI questionnaire is designed to study individual personality traits, emotional state, and adaptive mechanisms in adults.
The questionnaire text includes 566 items covering health status, habits, behavior, prevailing experiences and mood, attitudes toward various life events, interpersonal relationships, and orientation of interests. Processing yields scores on 10 basic scales as well as 3 validity scales designed to determine the subjects' attitude toward testing, evasiveness, or intentional distortion of results.
Appendix G9. Ich Struktur Test nach G. Ammon – Ammon's Ego-Structure Test (1978) (ISTA)
Russian title: Ammon's Ego-Structure Test.
Original title: Ich-Struktur-Test nach G. Ammon (ISTA).
Source: Ammon G. Das Verständnis eines Entwicklungsdefizits von Ich-Strukturen in Persönlichkeit und umgebender Gruppe als Grundlage für Wissenschaft und Praxis einer Dynamischen Psychiatrie. — Dynamische Psychiatrie, 1978, Jg. 11, s. 120-140.
Ammon's Ego-Structure Test. Questionnaire for assessing central personality functions at the structural level: a guide for psychologists and physicians / compiled by Yu.Ya. Tupitsyn, V.V. Bocharov, T.V. Alhazova et al. – St. Petersburg: Bekhterev Psychoneurological Research Institute, 1998 – 70 p.
Type (underline):
- rating scale
- index
- questionnaire
- other (specify)
Purpose: It is a questionnaire developed by the author and his associates. Central personality functions are registered: 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 G10. Locus of Control Questionnaire (LCQ)
Russian title: Method for Determining the Level of Subjective Control of Personality (LSC).
Original title: Rotter's Locus of Control Scale – Rotter, Julian B. (1966). Generalized expectancies for internal versus external control of reinforcement. Psychological Monographs: General and Applied. 80(1): 1–28. doi:10.1037/h0092976; Rotter, J. B. Social learning and clinical psychology. — New York: Prentice-Hall, 1954.
Source (official developers' website, validation publication): Bazhin E.F., Golynkina E.A., Etkind A.M. Method for studying the level of subjective control // Psychological Journal. — Vol. 5. — 1984. — No. 3. — P. 152-162.
Type (underline):
- rating scale
- index
- questionnaire
- other (specify)
Purpose: The questionnaire consists of 44 statements and is designed to diagnose internality-externality. It measures both the general level of internality and the personality's locus of control in various spheres of life. The level of subjective control is a generalized personality characteristic that manifests similarly in various situations.
The level of subjective control is associated with a person's sense of responsibility for events happening to them. The strategies a person chooses for their behavior can vary and depend on the social maturity and independence of the individual. Depending on how a person assesses the events of their life, what causes these events, and who is responsible 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 G11. Personal Beliefs Test (Kassinove H., Berger A., 1988) - Questionnaire for the study of personal beliefs
Russian title: Questionnaire for the study of personal beliefs.
Original title: Personal Beliefs Test (Kassinove Howard, 1988) - Kassinove H., Berger A. Survey of personal beliefs // Hofstra University: Personal communication—1988.—P. 100–113.
Source (official developers' website, validation publication): Adaptation of the method was carried out at the Bekhterev St. Petersburg Psychoneurological Research Institute. - 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. — St. Petersburg: Publishing House of the Bekhterev Research Institute. — 2011.
Type (underline):
- rating scale
- index
- questionnaire
- other (specify)
Purpose: The questionnaire was originally developed at Hofstra University (USA)
by Howard Kassinove and Andrew Berger (1981), and is intended for diagnosing rational thinking and identifying irrational beliefs (attitudes) characteristic of patients with neurotic disorders. The theoretical basis for creating the method was A. Ellis's rational-emotive psychotherapy. Later, the authors made some changes to the content of the questionnaire, the appropriateness of which was confirmed by factor analysis. The questionnaire includes 5 scales:
1. "Self-demandingness". 2. "Self-evaluation". 3. "Catastrophizing". 4. "Other-demandingness". 5. "Low frustration tolerance" and 6. General (integral) indicator of rational thinking. The main purpose of the questionnaire is to study respondents' rational and irrational ideas (attitudes).
Appendix G12. Life Style Index (LSI)
Russian title: Life Style Index.
Original title: Life Style Index (LSI, Kellerman-Plutchik, 1979). Plutchik R. A structural theory of ego defence and emotions / Emotions in personality and psychopathology / R. Plutchik, H. Kellerman, H. Conte; Ed. by E. Izard. - New York, 1979. - p. 229-257.
Source (official developers' website, validation publication): Adaptation of the method by L.I. Wasserman et al., St. Petersburg Bekhterev 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: methodical guide for doctors and psychologists. - St. Petersburg: Bekhterev Research Institute, 1998. - 48 p.
Type (underline):
- rating scale
- index
- questionnaire
- other (specify):
Purpose: A personality questionnaire designed to assess the severity of 8 main psychological defense mechanisms (8 scales derived via factor analysis): denial, projection, regression, compensation, repression, displacement, intellectualization, and reaction formation. The questionnaire consists of 97 questions and allows for 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 combination of scaled scores reflects the individual structure of a person's psychological defenses and, overall, their style of defensive behavior.
Appendix G13. Ways of Coping Questionnaire (WCQ).
Russian title: Ways of Coping Questionnaire adapted by R. Lazarus.
Original title: "Ways of Coping Questionnaire" (WCQ, Folkman S., Lazarus R., 1988). - Folkman S., Lazarus R. Manual for ways of coping questionnaire. - Palo Alto, CA: Consult. Psychol. Press, 1988.
Source (official website of the developers, validation publication): Adaptation of the method by L.I. Wasserman et al., St. Petersburg V.M. Bekhterev Psychoneurological Research Institute, Laboratory of Clinical Psychology. - Wasserman L.I., Iovlev B.V., Isaeva E.R. et al. Method for psychological diagnosis of coping strategies for stress and personal problem situations / Manual for physicians and medical psychologists. - NIPNI im. V.M. Bekhtereva Publ. - St. Petersburg, 2009. - 40 p.
Type (underline):
- rating scale
- index
- questionnaire
- other (specify):
Purpose: The questionnaire is widely used in domestic research to study stress-coping behavior (coping 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 via factor analysis). Each scale represents a specific standard behavioral option in a difficult situation: planned problem-solving, positive reappraisal, acceptance of responsibility, seeking social support, confrontation, self-control, distancing, and avoidance. Raw scores are calculated for each scale and converted into T-scores (percentiles) using a special formula. The combination of the 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 G14. Melbourne Decision Making Questionnaire (MDMQ)
Russian title: Melbourne Decision Making Questionnaire.
Original title: Melbourne decision making questionnaire – MDMQ. Mann L., Burnett P., Radford M., Ford S. The Melbourne Decision Making Questionnaire: An Instrument of Measuring Patterns for Coping with Decisional Conflict. Journal of Behavioral Decision Making, 1997, 10(1), 1–19.
Source (official website of the developers, validation publication): Adaptation of the method - 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 // Psikhologicheskiy zhurnal. 2010. Vol. 31. No. 1. P. 74–86; Kornilova T.V. Melbourne Decision Making Questionnaire: Russian-language adaptation // Psikhologicheskie issledovaniya. – 2013. – Vol. 6. – No. 31.
Type (underline):
- rating scale
- index
- questionnaire
- other (specify):
Purpose: This is a personality questionnaire aimed at diagnosing the individual decision-making style. The questionnaire is the result of testing the more general Flinders’ Decision Making Questionnaire (DMQ).
Validated in Russian by T.V. Kornilova, S.A. Kornilov, and M.A. Chumakova in 2010. Psychological studies of human decision-making under conditions of uncertainty include both the analysis of cognitive components and personal aspects of choice regulation.
The Melbourne Decision Making Questionnaire includes 22 statements, agreement with which is rated by the respondent on a 3-point scale. It allows for diagnosing four traits interpreted as productive (vigilance) and unproductive coping (avoidance, procrastination, and hypervigilance) in decision-making situations. Approximate testing time is 5-10 minutes.
Appendix G15. KON-2006 Neurotic Personality Questionnaire
Russian title: Neurotic Personality Questionnaire KON-2006
Original title: Kwestionariusz osobowości nerwicowej KON-2006 (Aleksandrowicz J., et al., 2006).
Source (guidelines for the application of the method): Aleksandrowicz J., Klasa K., Sobański J., Stolarska D. Kwestionariusz osobowości nerwicowej KON – 2006, Komitet Redakcyjno-Wydawniczy Polskiego Towarzystwa Psychiatrycznego, Biblioteka Psychoterapii Polskiej, Kraków, 2006, p. 72.
Source (official website of the developers, validation publication): Adaptation of the method - Isurina G.L., Trąbczyński P.K., St. Petersburg State University, Faculty of Psychology. Comparative study: Isurina G.L., Grandilevskaya I.V., Trąbczyński P.K. "KON-2006 Questionnaire" – a new method for studying neurotic personality traits / Meditsinskaya psikhologiya v Rossii: elektron. nauch. zhurn. – 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., Trąbczyński P.K., Gorbunov I.A. Neurotic Personality Questionnaire KON-2006 Guidelines St. Petersburg 2018 - 62 p.
Type (underline):
- rating scale
- index
- questionnaire
- other (specify):
Purpose: The KON-2006 questionnaire is intended for the clinical diagnosis of neurotic-spectrum personality traits and the assessment of the overall severity of neurotic disorders. Based on the self-report method, the questionnaire makes it possible to assess the degree of personality dysfunctions. Changes in this indicator occurring during treatment also make it possible to evaluate the impact of therapy on neurotic personality characteristics and, consequently, to assess 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 G16. Russian Universal Questionnaire for the Quantitative Assessment of Treatment Adherence (KOP-25)
Russian title: Russian Universal Questionnaire for the Quantitative Assessment of Treatment Adherence (KOP-25).
Original title: Russian Universal Questionnaire for the Quantitative Assessment of Treatment Adherence (KOP-25).
Source (official website of the developers, validation publication): Nikolaev N.A., Skirdenko Yu.P. Russian Universal Questionnaire for the Quantitative Assessment of Treatment Adherence (KOP-25). Clin. Pharmacol. Ther., 2018, 27(1), 74 - 78.
Type (underline):
- rating scale
- index
- questionnaire
- other (specify):
Purpose: A clinical-psychological test method designed for the quantitative assessment of treatment adherence in routine clinical practice. A standardized questionnaire version for the quantitative assessment of treatment adherence is proposed and recommended for inclusion in standard medical examination programs for individuals with chronic diseases. It can be used to identify patient cohorts requiring additional attention as insufficiently adherent to treatment. Characteristics of KOP-25: sensitivity – 93%, specificity – 78%, reliability – 94%.
The questionnaire is filled out by the respondent personally or with the assistance of an interviewer, and includes 25 questions with response options. It is filled out sequentially – from question 1 to 25. For each question, the respondent selects the most appropriate answer from the provided closed-ended list containing 6 possible options. Only one answer can be selected for each questionnaire question. The completed questionnaire is processed by the interviewer according to an algorithm. Results processing can be performed in both automated and manual modes. There are 6 scored response options for each question. Results processing is carried out in two stages.
At the first stage, technical indicators are calculated: "importance of pharmacotherapy", "importance of medical care", "importance of lifestyle modification", as well as "readiness for pharmacotherapy", "readiness for medical care", and "readiness for lifestyle modification". Each technical indicator is a simple sum of scores obtained from responses to the corresponding questions. The minimum possible value for each technical indicator is 5 points, and the maximum is 30 points.
At the second stage, adherence indicators are calculated: "adherence to pharmacotherapy", "adherence to medical care", "adherence to lifestyle modification", and the integral indicator "treatment adherence". Each indicator represents a value calculated for a specific respondent and expressed as a percentage of the theoretically possible maximum (taken as 100%).