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Barton S, Karner C, Salih F, et al. Clinical effectiveness of interventions for treatment-resistant anxiety in older people: a systematic review. Southampton (UK): NIHR Journals Library; 2014 Aug. (Health Technology Assessment, No. 18.50.)

Cover of Clinical effectiveness of interventions for treatment-resistant anxiety in older people: a systematic review

Clinical effectiveness of interventions for treatment-resistant anxiety in older people: a systematic review.

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Appendix 1Diagnostic criteria for anxiety disorders set out in DSM-IV and ICD-10 classification systems

DSM-IV diagnostic criteria9,100ICD-10 diagnostic criteria11
GAD
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 relationshipsC. 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)
PTSD
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
a

The DSM-IV distinguishes panic disorder with agoraphobia from panic disorder without agoraphobia; as indicated by criterion B under the heading of panic disorder.

Copyright © Queen’s Printer and Controller of HMSO 2014. This work was produced by Barton et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.

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Bookshelf ID: NBK262332

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