Anxiety disorders dsm 5 codes

Anxiety Disorders and Related DSM-5 Diagnostic Codes:

Anxiety Disorder

Paul Susic Leave a comment

Anxiety Disorders

According to the American Psychiatric Association, each of the anxiety disorders share the features of fear and anxiety. Fear is a healthy, rational response to either a real or perceived threat whereas anxiety is anticipatory and is in response to a possible perceived threat in the future.

Anxiety among the general population is very high with estimates as high as 18% or 40 million American adults experiencing anxiety disorders each year. Some researchers feel that the lifetime prevalence rate may be as high as 30%. Almost 50% of people who experience anxiety disorders also meet the criteria for depressive disorder. Clinicians recognize that there is a very high level of comorbidity (shared symptoms) between depressive disorders and anxiety disorders, and believe that there may be a possible shared genetic predisposition.

Anxiety disorders frequently persist over time. Because anxiety disorders are so uncomfortable and often disabling, they are frequently the focus of clinical attention. Anxiety disorders are very responsive to psychotherapeutic treatment modalities as well as medications geared toward their specific symptoms. Please see the following specific diagnostic criterion information related to the anxiety disorders.

Specific Anxiety Disorders and Related DSM-5 Diagnostic Codes:

309. 21 (F93 0) Separation Anxiety Disorder

312. 23 (F94.0) Selective Mutism

300. 29 ( . ) Specific Phobia
Specify if:
(F40.218) Animal
(F40.228) Natural Environment
( . ) Blood Injection-injury
(F40.230) Fear of Blood
(F40.231) Fear of Injections and Transfusions
(F40.232) Fear of Other Medical Care
(F40.233) Fear of Injury
(F40. 248) Situational
(F40.298) Other

300. 23 (F40. 10) Social Anxiety Disorder (Social Phobia) Symptoms, Diagnosis and Treatment
Specify if: Performance only

300. 01 (F41.0) Panic Disorder

( . ) Panic Attack

300. 22 (F40. 00) Agoraphobia

300. 02 (F41.1) Generalized Anxiety Disorder

( . ) Substance/Medication – Induced Anxiety Disorder

293. 84 (F06. 4) Anxiety Disorder Due to Another Medical Condition

300. 09 (F41. 8) Other Specified Anxiety Disorder

300. 00 (F41. 9) Unspecified Anxiety Disorder

Diagnostic Information and Criterion for Anxiety Disorders adapted from the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition American Psychological Association by Paul Susic Ph. D. Licensed Psychologist

anxiety disorderdiagnosis

Diagnostic criteria for anxiety disorders set out in DSM-IV and ICD-10 classification systems - Clinical effectiveness of interventions for treatment-resistant anxiety in older people: a systematic review

A. Excessive anxiety and worry (apprehensive expectation), occurring on more days than not for at least 6 months, about a number of events or activities (such as work or school performance)A. A period of at least six months with prominent tension, worry and feelings of apprehension, about every-day events and problems
B. The person finds it difficult to control the worryB. At least four symptoms out of the following list of items must be present, of which at least one from items 1 to 4
Autonomic arousal symptoms
  1. palpitations or pounding heart, or accelerated heart rate

  2. sweating

  3. trembling or shaking

  4. dry mouth (not owing to medication or dehydration)

Symptoms concerning chest and abdomen
  • 5. difficulty breathing

  • 6. feeling of choking

  • 7. chest pain or discomfort

  • 8. nausea or abdominal distress (e.g. churning in stomach)

Symptoms concerning brain and mind
  • 9. feeling dizzy, unsteady, faint or light-headed

  • 10. feelings that objects are unreal (derealisation), or that one’s self is distant or ‘not really here’ (depersonalisation)

  • 11. fear of losing control, going crazy or passing out

  • 12. fear of dying

General symptoms
  • 13. hot flushes or cold chills

  • 14. numbness or tingling sensations

Symptoms of tension
  • 15. muscle tension, or aches and pains

  • 16. restlessness and inability to relax

  • 17. feeling keyed up, or on edge, or of mental tension

  • 18. a sensation of a lump in the throat, or difficulty with swallowing

Other non-specific symptoms
  • 19. exaggerated response to minor surprises or being startled

  • 20. difficulty in concentrating, or mind going blank, because of worrying or anxiety

  • 21. persistent irritability

  • 22. difficulty getting to sleep because of worrying

C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). Note that only one item is required in children
  1. Restlessness or feeling keyed up or on edge

  2. Being easily fatigued

  3. Difficulty concentrating or mind going blank

  4. Irritability

  5. Muscle tension

  6. sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

C. The disorder does not meet the criteria for panic disorder, phobic anxiety disorders, obsessive–compulsive disorder or hypochondriacal disorder
D. The focus of the anxiety and worry is not confined to features of an Axis I disorder, e.g. the anxiety or worry is not about having a panic attack (as in panic disorder), being embarrassed in public (as in social phobia), being contaminated (as in obsessive–compulsive disorder), being away from home or close relatives (as in separation anxiety disorder), gaining weight (as in anorexia nervosa), having multiple physical complaints (as in somatization disorder), or having a serious illness (as in hypochondriasis), and the anxiety and worry do not occur exclusively during PTSDD. Most commonly used exclusion criteria: not sustained by a physical disorder, such as hyperthyroidism, an organic mental disorder or psychoactive substance-related disorder, such as excess consumption of amphetamine-like substances, or withdrawal from benzodiazepines
E. The anxiety, worry or physical symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning
F. The disturbance is not caused by the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition (e.g. hyperthyroidism) and does not occur exclusively during a mood disorder, a psychotic disorder, or a pervasive developmental disorder
Obsessive–compulsive disorder
A. Either obsessions or compulsions:
Obsessions as defined by (1), (2), (3) and (4):
  1. recurrent and persistent thoughts, impulses or images that are experienced, at some time during the disturbance, as intrusive and inappropriate, and that cause marked anxiety or distress

  2. the thoughts, impulses or images are not simply excessive worries about real-life problems

  3. the person attempts to ignore or suppress such thoughts, impulses or images, or to neutralise them with some other thought or action

  4. the person recognises that the obsessional thoughts, impulses or images are a product of his or her own mind (not imposed from without as in thought insertion)

Compulsions as defined by (1) and (2):
  1. Repetitive behaviours (e. g. hand washing, ordering, checking) or mental acts (e.g. praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly

  2. The behaviours or mental acts are aimed at preventing or reducing distress, or preventing some dreaded event or situation. However, these behaviours or mental acts either are not connected in a realistic way with what they are designed to neutralise or prevent, or are clearly excessive

A. Either obsessions or compulsions (or both), present on most days for a period of at least 2 weeks
B. At some point during the course of the disorder the person has recognised that the obsessions or compulsions are excessive or unreasonable. Note that this does not apply to childrenB. Obsessions (thoughts, ideas or images) and compulsions (acts) share the following features, all of which must be present:
  1. they are acknowledged as originating in the mind of the patient and are not imposed by outside persons or influences

  2. they are repetitive and unpleasant, and at least one obsession or compulsion must be present that is acknowledged as excessive or unreasonable

  3. the subject tries to resist them (but if very long-standing, resistance to some obsessions or compulsions may be minimal). At least one obsession or compulsion must be present that is unsuccessfully resisted

  4. carrying out the obsessive thought or compulsive act is not in itself pleasurable (this should be distinguished from the temporary relief of tension or anxiety)

C. The obsessions or compulsions cause marked distress, are time-consuming (take more than 1 hour a day, or significantly interfere with the person’s normal routine, occupational (or academic) functioning or usual social activities or relationships C. The obsessions or compulsions cause distress or interfere with the subject’s social or individual functioning, usually by wasting time.
D. If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g. preoccupation with food in the presence of an eating disorder; hair pulling in the presence of trichotillomania; concern with appearance in the presence of body dysmorphic disorder; preoccupation with drugs in the presence of a substance use disorder; preoccupation with having a serious illness in the presence of hypochondriasis; preoccupation with sexual urges or fantasies in the presence of a paraphilia; or guilty ruminations in the presence of major depressive disorder)D. Most commonly used exclusion criteria: not caused by other mental disorders, such as schizophrenia and related disorders, or mood (affective) disorders
E. The disturbance is not caused by the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition
Panic disordera
A. Both (1) and (2):
  1. recurrent unexpected panic attacks

  2. at least one of the attacks has been followed by 1 month (or more) of one (or more) of the following:

  3. persistent concern about having additional attacks

  4. worry about the implications of the attack or its consequences (e.g. losing control, having a heart attack, ‘going crazy’)

  5. a significant change in behaviour related to the attacks

A. Recurrent panic attacks that are not consistently associated with a specific situation or object and often occurring spontaneously (i. e. the episodes are unpredictable). The panic attacks are not associated with marked exertion or with exposure to dangerous or life-threatening situations
B. Absence of agoraphobia/presence of agoraphobiaB. A panic attack is characterised by all of the following:
  1. it is a discrete episode of intense fear or discomfort

  2. it starts abruptly

  3. it reaches a crescendo within a few minutes and lasts at least some minutes

  4. at least four symptoms must be present from the list below, one of which must be from items 1 to 4:

Autonomic arousal symptoms
  1. palpitations or pounding heart, or accelerated heart rate

  2. sweating

  3. trembling or shaking

  4. dry mouth (not caused by medication or dehydration)

Symptoms concerning chest and abdomen
  • 5. difficulty breathing

  • 6. feeling of choking

  • 7. chest pain or discomfort

  • 8. nausea or abdominal distress (e.g. churning in stomach)

Symptoms concerning brain and mind
  • 9. feeling dizzy, unsteady, faint or light-headed

  • 10. feelings that objects are unreal (derealisation), or that one’s self is distant or ‘not really here’ (depersonalisation)

  • 11. fear of losing control, going crazy or passing out

  • 12. fear of dying

General symptoms
  • 13. hot flushes or cold chills

  • 14. numbness or tingling sensations

C. The panic attacks are not caused by the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition (e.g. hyperthyroidism)C. Most commonly used exclusion criteria: not caused by a physical disorder, organic mental disorder, or other mental disorder such as schizophrenia and related disorders, affective disorders or somatoform disorders
D. The panic attacks are not better accounted for by another mental disorder, such as social phobia (e.g. occurring on exposure to feared social situations), specific phobia (e.g. exposure to a specific phobic situation), OCD (e.g. on exposure to dirt in someone with an obsession about contamination), PTSD (e.g. in response to stimuli associated with a severe stressor) or separation anxiety disorder (e.g. in response to being away from home or close relatives)
A. The person has been exposed to a traumatic event in which both of the following were present:
  1. the person experienced, witnessed, or was confronted with an event, or events, that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others

  2. the person’s response involved intense fear, helplessness or horror. Note that in children this may be expressed instead by disorganised or agitated behaviour

A. Exposure to a stressful event or situation (either short or long lasting) of exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone
B. The traumatic event is persistently re-experienced in one (or more) of the following ways:
  1. recurrent and intrusive distressing recollections of the event, including images, thoughts or perceptions. Note that in young children repetitive play may occur in which themes or aspects of the trauma are expressed

  2. recurrent distressing dreams of the event. Note that in children these may be frightening dreams without recognisable content

  3. acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note that in young children trauma-specific re-enactment may occur

  4. intense psychological distress at exposure to internal or external cues that symbolise or resemble an aspect of the traumatic event; physiological reactivity on exposure to internal or external cues that symbolise or resemble an aspect of the event

B. Persistent remembering or ‘reliving’ the stressor by intrusive flash backs, vivid memories, recurring dreams or by experiencing distress when exposed to circumstances resembling or associated with the stressor
C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:
  1. efforts to avoid thoughts, feelings or conversations associated with the trauma

  2. efforts to avoid activities, places or people who arouse recollections of the trauma

  3. inability to recall an important aspect of the trauma

  4. markedly diminished interest or participation in significant activities

  5. feeling of detachment or estrangement from others

  6. restricted range of affect (e. g. unable to have loving feelings)

  7. sense of a foreshortened future (e.g. does not expect to have a career, marriage, children or a normal life span)

C. Actual or preferred avoidance of circumstances resembling, or associated with, the stressor (not present before exposure to the stressor)
D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
  1. difficulty falling or staying asleep

  2. irritability or outbursts of anger

  3. difficulty concentrating

  4. hypervigilance

  5. exaggerated startle response

D. Either (1) or (2):
  1. inability to recall, either partially or completely, some important aspects of the period of exposure to the stressor

  2. persistent symptoms of increased psychological sensitivity and arousal (not present before exposure to the stressor), shown by any two of the following:

    1. difficulty in falling or staying asleep

    2. irritability or outbursts of anger

    3. difficulty in concentrating

    4. hypervigilance

    5. exaggerated startle response

E. Duration of the disturbance (symptoms in Criteria B, C and D) is more than 1 monthE. Criteria B, C and D all occurred within six months of the stressful event or the end of a period of stress (for some purposes, onset delayed more than six months may be included but this should be clearly specified separately)
F. The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning
Social anxiety disorder
A. A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. Note: in children, there must be evidence of the capacity for age-appropriate social relationships with familiar people and the anxiety must occur in peer settings, not just interactions with adultsA. Either (1) or (2):
  1. marked fear of being the focus of attention or fear of behaving in a way that will be embarrassing or humiliating

  2. marked avoidance of being the focus of attention or situations in which there is fear of behaving in an embarrassing or humiliating way

These fears are manifested in social situations, such as eating or speaking in public; encountering known individuals in public; or entering or enduring small group situations, such as parties, meetings and classrooms
B. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed Panic attack. Note: in children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations with unfamiliar peopleB. At least two symptoms of anxiety in the feared situation at some time since the onset of the disorder, as defined in criterion B for agoraphobia and in addition one of the following symptoms:
  1. blushing

  2. fear of vomiting

  3. urgency or fear of micturition or defaecation

C. The person recognises that the fear is excessive or unreasonable. Note: in children, this feature may be absentC. Significant emotional distress caused by the symptoms or by the avoidance
D. The feared social or performance situations are avoided or else are endured with intense anxiety or distressD. Recognition that the symptoms or the avoidance are excessive or unreasonable
E. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person’s normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobiaE. Symptoms are restricted to, or predominate in, the feared situation or when thinking about it
F. In individuals under age 18 years, the duration is at least 6 monthsF. Most commonly used exclusion criteria: Criteria A and B are not caused by delusions, hallucinations or other symptoms of disorders such as organic mental disorders, schizophrenia and related disorders, affective disorders or OCD, and are not secondary to cultural beliefs
G. The fear or avoidance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition and is not better accounted for by another mental disorder (e.g., panic disorder with or without agoraphobia, separation anxiety, body dysmorphic disorder, a pervasive developmental disorder, or schizoid personality disorder)
H. If a general medical condition or another mental disorder is present, the fear in Criterion A is unrelated to it, e.g. the fear is not of stuttering, trembling in Parkinson’s disease, or exhibiting abnormal eating behaviour in anorexia nervosa

ICD-10 and DSM-V: differences in the diagnosis of eating disorders

“Today there are 2 main guidelines that specialists from different countries rely on to classify and diagnose all existing diseases, including eating disorders. These are the ICD (International Statistical Classification of Diseases and Related Health Problems) and the DSM (Diagnostic and Statistical Manual of Mental Disorders).

Of course, there are also national guidelines and classifications. For example, in Soviet psychiatry, such a type of schizophrenia as sluggish schizophrenia was separately distinguished, although such a diagnosis is generally absent in international classifications.

Nevertheless, qualified specialists are guided by the ICD or DSM in their work.

The ICD has more than three hundred years of history and is currently the official regulatory document of the World Health Organization.

ICD went through 10 editions. The current ICD-10 is used, which has been in use in WHO Member States since 1994. And work is already underway on the ICD-11, which is planned to be introduced after 2018.

It is important to note that ICD-10 covers all diseases. Mental and behavioral disorders are presented there only in a separate chapter. And eating disorders are not singled out in a separate rubric in this chapter, but are included in a broader rubric - Behavioral Syndromes Associated with Physiological Disorders and Physical Factors.

This heading has a subheading "Eating Disorders" (code F50), which includes:

  • anorexia nervosa
  • bulimia nervosa
  • overeating associated with other psychological disorders
  • Vomiting associated with other psychological disorders
  • other eating disorders
  • Eating disorder, unspecified

The fundamental point is that in the ICD-10 there is only a classification and key features of eating disorders. And that's it! Data on detailed description of criteria, prevalence, differential diagnosis, etc. in the ICD, unfortunately, you will not find.

Regarding the DSM, this guide was originally developed by the American Psychiatric Association. The first edition (DSM-I) was in 1952. Now the 5th edition (DSM-V), released in 2013, is already in use. This edition is not available in Russian.

A distinctive feature of this manual is the detailed classification and, most importantly, the description of mental disorders (hence the name).

In particular, a separate section is devoted to eating disorders.

The following eating disorders are distinguished in it:

  • “peak” (perverted appetite)
  • chewing disorder
  • avoidant/restrictive eating disorder
  • anorexia nervosa
  • bulimia nervosa
  • overeating
  • other specific eating or eating disorders
  • non-specific eating or eating disorders

An important difference of the DSM-V is that, unlike the ICD-10, for each of the major eating disorders are given:

  • criteria for diagnosing eating disorders
  • extended explanation for each criterion
  • subtypes or severity of disorder
  • diagnostic features
  • data on the prevalence of the disorder
  • information on the course and development of the disease
  • risk factors
  • specific diagnostic markers
  • suicide risk data
  • consequences of an eating disorder
  • differential diagnosis
  • relationship with other psychiatric disorders (not related to eating disorders).

In addition, DSM-V is the most current version released in 2013. It presents the latest data on the criteria for mental disorders, some of which differ from those in earlier versions of the guide.

This also applies to eating disorders.”

The author of the article is Sergei Leonov, source

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Clinical features of the combination of agoraphobia and non-psychotic mental disorders | Kovalev


Russian and English articles were searched in the databases, Web of Science, Scopus, Clinical Case, PubMed, Cochrane Database of Systematic Reviews. Articles were searched using the keywords "agoraphobia", "anxiety disorders", "borderline mental disorders". Inclusion criteria — full-text articles in Russian and English, original research, Cochrane reviews, clinical observations, publication date from 1994 to 2020 Exclusion criteria - abstracts, abstracts, publication date before 1994. A total of 734 publications were found. 43 publications met the inclusion/exclusion criteria.

Agoraphobia is a disorder characterized by the appearance of fear when the patient is in open space or in crowded places (shops, bus stops) with the subsequent formation of behavior to avoid situations that caused fear. According to the classification given in the ICD-10, it can be divided into two groups: agoraphobia without anamnestic data for panic disorder and panic disorder with agoraphobia (ICD-10). Some researchers distinguish agoraphobia with early and late (after 65 years) onset [1].

The prevalence of panic disorder is estimated at about 2% of the population per year, or about 2–5% of the population during a lifetime [2][3]. Among these patients, one-third to one-half have agoraphobic symptoms, although the percentage is even higher in clinical samples [4]. Such a fairly high percentage of agoraphobia in the population makes this topic relevant for research.

Recent research results show a comorbidity between agoraphobia and other anxiety spectrum disorders. In particular, agoraphobia occurs in 0.8% of people who have had a panic attack, in 1.1% with panic disorder [2]. It has also been shown that a third of patients with panic disorder and major depressive disorder develop agoraphobia [5].

It is important to note that comorbidity increases the severity of the disease and reduces the effectiveness of the treatment. The nosologies listed above are combined into a group of borderline mental disorders that have a high percentage of occurrence in the population [6]. Some of them, in particular PTSD (post-traumatic stress disorder), may be factors that shape the development of agoraphobia, so it is important to strive to reduce the prevalence of these nosologies [7].

Another factor in the importance of work in this direction is the fact that agoraphobia significantly aggravates the course of panic disorder and worsens the quality of life of patients, assessed on the SF-36 scale [8].

Taking into account the prevalence of the disease and the decrease in the quality of life in patients, the selection of effective therapy for panic-agoraphobic states plays an important role [9][10].

Panic attacks and panic disorder as the basis for the formation of agoraphobic symptoms

It can be said that the position of agoraphobia as a separate nosology was very "shaky" for a long time. In particular, there was a question about the secondary formation of agoraphobia in relation to panic disorder. Or is it a separate nosological unit, as it was originally indicated in the ICD? 99 neurosis ) . Subsequently, agoraphobia was included in the ICD-9 as an independent syndrome, manifested by multiple fears, and in the ICD-10 it occupies the same status (ICD-10, 1995).

In the United States, where the DSM is the main system for classifying mental disorders, agoraphobia is defined as "feelings of fear with avoidant behavior, formed when you are alone or among people in places from which it is difficult to get out or get medical help in an emergency." It can be said that this definition is similar to the definition of panic disorder and the definition of agoraphobia given in ICD-10. However, the DSM definition of agoraphobia is closer to panic disorder than to phobias. Agoraphobia with panic attacks should be coded as its initial phase, when there are recurrent panic attacks, which in turn leads to the development of fear of such an attack and, accordingly, the avoidance of situations and places that can provoke such an attack. If there is no history of panic attacks, then the diagnosis is agoraphobia without panic attacks, but according to the DSM, avoidance behavior is required to be the result of anxiety about the development of a panic attack, that is, in any case, an association is indicated between a panic disorder or attack and agoraphobia , which is the difference between this classification and ICD-10. Thus, with the DSM-III-R, agoraphobia was defined as a response to situations in which a panic attack occurred. However, the evolution of subsequent revisions of the DSM has been towards greater acceptance of agoraphobia outside of the construct of panic attacks or panic disorder. The DSM-V classification, released in 2013, has undergone significant changes to the heading of anxiety disorders, including agoraphobia and panic disorder. In particular, they were divided into two separate diagnoses, that is, when formulating a diagnosis, two different codes should be used. It can be said that the diagnostic criteria for agoraphobia have undergone only minor changes. In particular, it is necessary to confirm the occurrence of fear in two or more situations in order to exclude other phobias (APA, 2013).

Panic disorder is a chronic disease, resulting in patients requiring long-term therapy [11]. At the same time, agoraphobia has been shown to be a predictor of poor outcome in individuals with panic disorder [11]. The presence of agoraphobia in such patients exacerbates the clinical course of panic disorder and increases the likelihood of having one or more comorbid psychiatric disorders compared with patients with panic disorder but without agoraphobia. It has been shown that after a panic attack, 37% of patients exhibit moderate avoidance behavior, with 81% of these patients developing such behavior in less than a year [12]. Researchers have identified risk factors that increase the risk of developing agoraphobic symptoms, such as early age at onset of panic attacks [13], female gender [14], and belonging of the underlying disease to the anxiety spectrum group [12]. According to the data of domestic researchers, the predominant sex of patients with panic disorder and agoraphobia is female, and the age of the onset of the disease is 21–30 (32.4%) and 31–40 (35.3%) years, which corresponds to the data of foreign scientists [15 ].

Features of the clinical picture of anxiety spectrum disorders in combination with agoraphobia

Generalized anxiety disorder is a mental pathology that demonstrates a high degree of comorbidity with other nosologies. In particular, it has been shown that the lifetime incidence of major depressive disorder in generalized anxiety disorder is 62.4%, agoraphobia is 25.7%, and panic disorder is 23.5% [16].

Domestic studies have shown the comorbidity of agoraphobia and somato-vegetative type of generalized anxiety disorder, which is manifested by short-term somatized anxiety reactions during the day 1 . Among other disorders that are comorbid with anxiety disorder, of interest is irritable bowel syndrome, which leads to the development of agoraphobia. This is due to the fact that patients are afraid to experience the manifestations of this syndrome in public, which forms avoidant behavior [17].

The impact of agoraphobia on the course of depressive disorders

Studies have shown that the comorbidity of depression and panic disorder with agoraphobia is associated with increased anxiety, hypochondria, feelings of “inadequacy”, social isolation, as well as with treatment failure, difficulties in psychosocial rehabilitation, and an increase in the frequency of hospitalization [ 18]. Also, the severity of depressive symptoms (feelings of guilt, hopelessness) increases in the presence of panic disorder with agoraphobia [19]. Sareen J. et al., 2005 [20] showed that panic disorder with agoraphobia is associated with a history of suicide attempts. This is very important because a history of a suicide attempt is regarded as a predictor of further suicide attempts. Some researchers believed that the presence of a suicide attempt in patients suffering from major depressive disorder is not associated with the presence of panic disorder, since the presence of anxiety, hypochondria was regarded as a protective factor against suicidal behavior, since these patients were more afraid of death [21]. Other researchers believed that there is a link between psychomotor agitation and suicidal ideation, which contradicts the hypothesis of anxiety as a protective factor against suicide [22]. The key point in these hypotheses is the existence of a link between depressive and anxiety spectrum disorders.

It has been studied for a long time what factors associated with panic-agoraphobic symptoms can lead to an increased risk of suicidal behavior, in addition to the influence of depression. Patients with comorbidity of anxiety and depression may commit suicide more often than patients without anxiety, as this is a way to get rid of the symptoms that worry them [20]. Panic attacks during depression significantly impair social functioning, which in turn can lead to suicidal ideation.

It should be noted that there is an inverse effect of depression on agoraphobia, in particular, there is an increase in the severity of phobic symptoms [23].

Thus, there is a complex pathogenetic relationship between panic-agoraphobic symptoms and depression. In this regard, the study of this issue is very important, as it will help reduce the likelihood of suicidal behavior.

PTSD as an etiological factor in agoraphobia

Studies have shown a high comorbidity between panic disorder and PTSD. Thus, panic disorder occurs in 7.3-18.6% of men and 12.6-17.5% of women suffering from PTSD [24]. More recent studies have shown that 35% of patients with PTSD experienced panic attacks within a year, leading to increased comorbidity with other anxiety spectrum disorders and impaired social functioning [25].

The relationship between PTSD and panic disorder is emphasized in connection with the emergence of a circular model of the development of fear, which postulates a similar etiology of anxiety disorders based on this emotion [26]. Applying this hypothesis to PTSD and panic disorder, we can say that in a situation that triggers a reminder of a physical threat, a person experiences tachypnea, heart pain and fear of death. The hypothesis of the circular formation of a feeling of fear is in good agreement with the assumption that panic during a traumatic event becomes part of a conditioned reflex that can start at a certain moment, demonstrating the above symptoms [27]. In this case, agoraphobic symptoms can form, when patients avoid those places that cause a panic attack and experience anxiety about its likely development [13].

The impact of personality disorders on the clinical picture of agoraphobia

Understanding how personality traits are associated with panic disorder and agoraphobia is an important step in understanding the etiology of the latter. Researchers have shown that cluster C (“anxiety” group) of psychopathy, especially avoidant and dependent, are associated with anxiety disorders, in particular with panic disorder and agoraphobia [28]. It should be noted that some researchers dispute the view that these types of personality disorders are predisposing factors for panic disorder and agoraphobia, based on retrospective data on the premorbid personality structure of patients with anxiety disorders. Other researchers believe that in the early stages of the course of a panic disorder, the symptoms of the disease cannot affect the deformation of the personality [29]. This point of view can be supported by the fact that effective treatment of panic disorder and agoraphobia can neutralize pathocharacterological personality traits [30].

It is known that the personal characteristics of patients can have a significant impact on the prognosis of therapy. Thus, in the study by M. Ozkan and A. Altindag, 2005 [31] it was shown that those patients in whom characterological features reach the severity of psychopathic, panic disorder is characterized by a more severe course, agoraphobic symptoms are more often associated, and the risk of suicide is higher.

Among the factors that form personality, in addition to genetically determined personality traits, upbringing plays an important role. Domestic researchers have shown that a disharmonious type of upbringing was very often applied to patients with agoraphobia. The most common style is “hyperresponsibility and hyperprotection” (50.98%), which correlates with social anxiety and social phobia. The next most common (24.11%) parenting style was "Cinderella", as a result of which patients have a complex of guilt and addiction, and the ban on the manifestation of negative emotions led to somatization of anxiety 2 .

Influence of the type of hypochondria on the dynamics of agoraphobia

After a panic attack, patients often develop anxiety in anticipation of a second attack, which is updated if it is necessary to stay in a situation that can trigger a phobic reaction (anxiety, a feeling of tension in the body, tachycardia, shortness of breath). These manifestations could be accompanied by the development of hypochondriacal disorders. Fear for health was in the nature of obsessive hypochondria with an understanding of the morbidity and groundlessness of the phobia and the fight against it, but sometimes hypochondria can take on the character of overvalued. The latter option is distinguished by the absence of a critical attitude to one's condition [18].

In the work of I. B. Poze 3 it was also found that all patients suffering from agoraphobia have comorbidity with hypochondriacal disorders: from the degree of fixation to obsessive nature. Neurotic hypochondria was characterized by the specificity of nosophobia with somato-vegetative manifestations. The clinical picture was characterized by a change of syndromes, such as hypochondriacal manifestations and pathocharacteristic changes in personality overlapped the picture of phobia. Subsequently, the clinic of neurotic development was determined by a complex obsessive-phobic and hypochondriacal complex. Interestingly, according to the results of this work, it was revealed that the overvalued type of hypochondriacal disorders was formed in patients with personality disorders. So, in anxiety, anancaste and dependent personality disorders, hypochondriacal development was revealed with an accentuation of perfectionism, a change in priorities and values, and a “break in the life curve”. The hysterical personality showed a more favorable course. There was a partial reduction of hypochondria with the restoration of the previous level of functioning. Thus, we can say that the presence of a hysterical radical in the personality structure is prognostically favorable, while an anacastic, anxious and dependent one is unfavorable. At the same time, the clinical picture of hypochondria determines the dynamics of the course of agoraphobia. With neurotic hypochondria, long-term remissions without psychopathological disorders were observed, and with overvalued hypochondria, a continuous course with generalization and complication of the clinical picture due to the formation of comorbid relationships was observed.

Research in this direction abroad took place in the eighties. Hypochondria was seen as a somatic manifestation of a violation of self-perception, and agoraphobia as a defensive reaction and an attempt to restore a disturbed self-perception. It has also been shown that patients can endure panic attacks earlier without understanding their psychological etiology, but that they may be the key moment in the formation of hypochondria or an anxious temperament.

Agoraphobia as part of sluggish schizophrenia

Although most of the study of the comorbidity of anxiety disorders and schizophrenia dates back to the early years of the nosological approach in psychiatry, for a long time this topic was ignored by both clinicians and researchers [32]. This was probably due to the fact that for a long time in the DSM diagnostic criteria it was indicated that an anxiety spectrum disorder can be diagnosed if there is no connection with the disorder of the first axis, in particular schizophrenia, which led to a low diagnosis of this nosology in patients with schizophrenia. [33]. However, with the advent of the DSM-III-R, the diagnosis of comorbid anxiety disorder was allowed if its manifestations were not associated with an underlying mental illness. The second reason for the increased interest in this problem at the moment is that the presence of a comorbid anxiety disorder negatively affects the rehabilitation of patients and their degree of functioning [34]. Thus, the treatment of anxiety spectrum disorders in patients with schizophrenia is necessary, as it increases the likelihood of achieving a favorable outcome [35]. In a meta-analytic study by A. M. Achim et al., 2009, which included 52 studies with a total of 4,032 patients, examined the frequency of anxiety spectrum disorders in patients with schizophrenia. The authors showed that the average prevalence of agoraphobia in this cohort of patients is 5.4%, 95% confidence interval lies in the range from 0.2% to 10.6% [36].

In the Russian school of psychiatry, it is customary to single out a sluggish type of schizophrenic process, which in the American school is regarded as a schizotypal personality type. The endogenous process in this case is characterized by the absence of pronounced positive symptoms, but against the background of a “delayed” course [37]. Some researchers consider agoraphobia as part of a defect formed as a result of a sluggish process 4 [40].

According to Russian studies, the onset of agoraphobia in patients with schizophrenia occurs in adulthood. The main plot of the phobia is the fear of being alone in a confined space and the fear of independent movement on the street. Interestingly, agoraphobic symptoms were formed not only against the background of panic disorder, but also in patients with synesthesia [38].

Effect of agoraphobia on the clinical picture of chronic alcoholism

In Germany, U. Schneider and A. Altman, 2001 conducted a large retrospective epidemiological study MUCPA (Multicentre Study of Psychiatric Comorbidity in Alcoholics - Multicenter Study of Comorbidity with Psychiatric Diseases among Alcoholics), the purpose of which was to determine the prevalence of comorbid psychiatric disorders among people suffering from alcoholism . The study included 556 patients suffering from alcoholism (patients who also used other psychoactive substances were excluded from the study). Anxiety disorders were found in 42.3% of those surveyed. Generalized anxiety disorder was diagnosed in 42.3%, agoraphobia in 12.9%.%, social phobia — in 13.1%, panic disorder — in 13.7% of the examined [39].

According to K. Tomasson and P. Vaglum (1996), in the presence of agoraphobia/panic disorder, the risk of re-treatment for alcoholism after detoxification is 6 times higher in individuals with less than two previous visits [40].

Domestic studies have shown that the picture of panic disorder with agoraphobia worsens if the patient has chronic alcoholism (in particular, the frequency of attacks increases), while the presence of agoraphobic symptoms leads to a relapse of alcoholic disease, which is explained by the use of alcohol to relieve symptoms [35 ]. The same authors showed that in the presence of chronic alcoholism, agoraphobic symptoms in panic disorder develop faster, and the quality of remission is significantly lower than in patients without alcohol dependence.

Domestic researchers have revealed a high incidence of dependence on tranquilizers, while this phenomenon is more common in people with an unfavorable course of agoraphobia 5 .


Summarizing the above, it can be noted that agoraphobia is still an urgent problem for both the clinician and the researcher. An analysis of the literature showed that, probably due to the dominance of "American" views on this nosology, it was inextricably considered secondary to panic disorder. In turn, this has led to a lack of data on agoraphobic symptoms. However, even from this material it is clear that this disorder is a serious problem for a psychiatrist due to the fact that it is not rare, while it aggravates the clinical picture of other mental illnesses. In particular, as mentioned above, it increases the risk of suicidal behavior in depression, reduces the effectiveness of therapy for schizophrenia spectrum disorders and the quality of life of patients, leads to a relapse of chronic alcoholism, and also increases the likelihood of developing dependence on tranquilizers.

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