Dr. Bruce Chung shares the case of a 50-year-old patient with a diagnosis of generalized anxiety disorder and a history of childhood and adult trauma. Dr. Chung seeks diagnostic clarification, pharmacological consultation, and support identifying appropriate behavioral health and psychosocial referrals. He also raises the question of whether a family physician is the most appropriate provider to manage this patient’s anxiety over a long period of time. Dr. Vanessa Litoff then discusses screening for anxiety, focusing particularly on panic disorder and obsessive-compulsive disorder (OCD). She explains barriers to screening for anxiety, common screening tools, symptomatology, and patient and physician resources.
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Case Presentation Case Discussion Didactic Presentation Didactic Q&A I hope what you hear today will help you support this patient. Okay, I'll turn it over to you. Thank you. What is really here. Okay, that's the first son analyze be music. So I'm very happy to be presenting at Mount Sina Echo Live. And as dr iris said, this is my second time presenting. I'm looking forward to it. Many of you don't know me, you know, I've been, there's a new thing going around that I'm involved in. It's called COVID-19. It's been playing in all the offices around new york city. It's a big hit. Everybody knows about him, anybody hear about this thing Avengers. Endgame, I'm not in there. But you know, there's this new thing called a new project Covid and Game. Uh what's that? I don't think that one's ready yet. So that would be uh you know, in the future. All right, that's my beginning jokes here. So I'll take the next slide. Alright, so I chose this patient because I've known him for a long time, probably 20 years. And then she did not start out like an anxiety patient. She was just a young woman who had sore throats and fatigue and headaches, all those things. But over time it became clear she had some other issues going on. So this is the story of those issues. So she's a 15 year old female. She has commercial insurance. She's employed full time as our teacher at Berkeley Carroll School the school in Manhattan and she lives with her spouse and has two Children that are teenagers. She has hypothyroidism is well controlled currently on both their oxen and you can see there are medicines The appraisal land is only as needed. Maybe I'll give her 20 pills in a year and should use them intermittently. And in the past it surprised me when you hear the story about her that she really never used any kind of other S. S. R. I. S. Or other medicines for whole life until the last I think five years. All she used was alprazolam intermittently from other providers. Okay next line so I feel that she's got generalized anxiety and currently she's well controlled. So there may not be any suggestions about what to do for her in the future. But I like I like to just tell her the story about what happened to her. So she had all the symptoms of anxiety palpitations, fear of losing control. You know, fears that she was going to die, paris. These Asia's worrying all the time. Lots of worrisome thoughts, uh inability to sleep because she ruminates about all her um worries, uh fatigue palpitations, headache. And she even has a stroke like episode. So she fits all the check boxes for somebody with anxiety. So next line please. So let's see from maybe I think I started seeing her around 2000 but from 2008 to 2,016 she had many, many visits in her office with multiple providers for fatigue, headaches, palpitations. But all the work up was never very conclusive. Nobody could find a reason for them. She saw a cardiologist neurologist and nothing ever ever was found. And she talks about she had many years of this all or nothing thinking where she'd get a job and then she was very happy for the first couple of months. But because she couldn't get everything she wanted. Well that was the worst job in the world should quit. Or she had a big bout of infertility. So I must have this child if I can get this child you know maybe I shouldn't be around or maybe I have to get divorced. So many episodes of everything has to be her way or it can't work. And then uh in 2014 she went to a retreat in bali you know she's an artist and a writer and she was trying to write a book about her life while she was there. She was hospitalized for seven days with headaches and the stroke like symptoms where she was shaking and couldn't move her arms. So while she was there they had M. R. I. C. T. S. All normal. And then when she returned I sent her to a neurologist here and her full evaluation was normal. And he diagnosed her with migraines and prestige is due to hyperventilation. So she was fine for a while and then she continued to complain of insomnia bloating and anxiety and through this whole time since I've known him for a while I would suggest, well maybe you should try some medicines, but she would never really want to take up because of fear from side effects or other family members may have taken the medicines and she was too fearful. So here's some uh God seven generalized anxiety disorder screens in 2016, it was 13 and I think after her medicine, it was 0-3. Further back into history when she was in college, she was seen by multiple psychiatrists and therapists. And even at one time she had to see a therapist every other day in order to stay in college, You can see her family history of psychiatric history was significant and her brother died. He shot himself. Her mother was alcoholic and I don't think I know how she died. I know it was by suicide, but I'm not sure the method and the patient was only 26 years old. And when I asked her about her mother, she says, the only way I could get her to be treated for alcoholism was call 911 when she was passed out on the couch. And then all she can say about her father was, he was very unkind history of trauma. She didn't have any um um physical trauma, but lots of verbal and emotional trauma. Her parents were actually very wealthy and her family was very wealthy, but there was some kind of issue going on where they all had to look a certain way and she couldn't fulfill that. That look of course, if you look at her history, mother was alcoholic, brother had some issues. So even though they were very wealthy and trying to put out a special image, it wasn't really like that in real life. Alright, next slide, please. The only medicine she's on right now is the telegram, five mg and the appraisal and that she takes intermittently. So, I just wanted to bring about this case to say that uh I'm a family doctor, I'm not a psychiatrist and looking to see if the things I should have done differently. Should I be the only one taking care of this patient? Should other people be involved? And the main question is is it appropriate for a family doctor to take care of someone like this? Or is the family doctor the most appropriate person to take care of somebody like this? So, I'd like to hear what people think and uh what we can do for her. All right, that's it. I turned it back to you, thank you so much. Um you know, as always, I I am so grateful for how much thought you put into your patients dr Cheung. And even the question you're asking, I appreciate is sort of, you know, almost somewhat like existential to some extent, I think from a clinical practice standpoint, which I really appreciate that as a clinician. You're stepping back and wondering and considering that I I imagine most of us who are in some form of clinical practice have those moments where we sort of wonder am I the right person or you know, for a variety of reasons. Um I'm really curious to hear what the group has to say. As far as questions. Um comments suggestions for doctor chang particularly given that the question that he's asking is one that is so important um and yet kind of abstract. Um so you know, I don't, I have some questions myself but I'll wait to see what others have by way of suggestions and questions. Dr brody go for it. Okay, I think I admitted myself, so you should be able to hear me. Um really interesting case and and probably the kind of case that um all of us, at least in behavioral health, you know run into free frequently and I'm sure a lot in in family practice as well diagnostically obviously there's more than generalized anxiety and panic that sort of going on here. And certainly the the length of her symptoms, the kinds of symptoms suggest a more enduring condition. Probably meeting criteria for some kind of a personality disorder. There's also diagnostically lots of lots of trauma uh and obviously losing her mother and her brother to suicide has to be you know, high in the list for that. So the question you ask is a great one, you know who's who's best to you know to manage someone like this. What's interesting is that the most recent research on the psychotherapy of borderline personality disorder. Um Not saying she meets that criteria, but certainly it would be in the differential suggests that regular psychotherapy not necessarily anything specialized like DBT dialectical behavioral therapy is a form of cognitive therapy or other sorts of specialist psychotherapy, but just sort of regular general supportive psychotherapy is probably as good as any anything else. And I think that that may be in fact what you're providing is a kind of supportive psychotherapy. And it may be that uh she has uh you know, a good relationship with you, there's a good therapeutic alliance. She feels that you're reliable, you're in her corner, your expert. Um uh maybe you know, as you know, as good if not better than than than a specialty referral. On the other hand, of course, you've got to be honest, in terms of your own um capacity for managing someone like this. And so certainly having a psychiatrist or a therapist or or both sort of on your team uh is probably helpful to this patient. I guess she does have a therapist. But what she says is my friend who whenever there's a bad situation I talked to my friend, so who's a therapist. So I think she does have someone she talks to me, I'm not the only one she talks to, but are you in touch with the therapist? Um I have not met or spoken with that therapist. I think that might be useful. But just to clarify, the therapist is not officially her therapist. It's a friend who also happens to be a therapist. Is that right? She is a friend and she's a therapist. But I'm not sure exactly how the relationship is, whether it's official or just you know, she calls her whenever she needs her. Right. Okay. I think that's perhaps an important distinction as well. And one that in itself kind of makes me then wonder about how she approaches relationships and the importance of clarifying the diagnosis in her personal elements of her uh presentation. Um dr brody. Any other thoughts or questions? No, I'd love to hear from other people. Thank you something about that. I remember when we finally put her on. So I've known I've known her for maybe 10, 15 years and I always you know, she's a difficult person to take care of. So whatever you do, it's not right. And she never really gets better. And so finally I said well you should try. Her husband came in, her husband's at the end of his rope. And so since I knew her for all the this time, she finally says okay I'll take it because I gave her many other things before, antibiotics, whatever. And so sometimes you need just the person who's hanging around, I happened to be in the right spot here. Take this medicine and then it turned her around. She's doing really well now. So it just happens if you're in the right spot when they're ready to hear something and ready to take something then it works out. All right. You just gotta be persistent maybe. Um Hi I'm sorry I just a little bit later and I missed some of the presentation but I was just going through the slides and like picking up on some of the information that you have provided in there. Um And you're right, it does sound like a difficult patient. And I you know your question about like should a family physician be the person to manage I think really rings true for a patient like this. And just like you said, I think you just happened to be the right person that she trusted. Um Because from her history, the past history it looks like she's had um depression and anxiety earlier and she has been seen by multiple psychiatrist but she seems to have not developed a appreciation or trust. So as to say maybe in the field maybe it's the people that she saw, maybe the therapist that she saw for some reason, despite having a history earlier in her life, she doesn't feel like she needs to go back. Um the history of suicide in her family. That is pretty significant too. Because if you think if if a brother died and the mother died um she should have gotten some kind of treatment and help um early on in her life. Um Which doesn't sound like either she got it and it wasn't good or she never got it. So it's a very interesting like this would be someone that we see in our outpatient practice. This is not someone that would be commonly managed uh in a primary care program. Um But it sounds like your relationship with her is what seems to have lasted for her and for whatever reason she trusts you and because you offered her the medication she's okay to take it. Um And if she's doing great with it then that's perfect. That's you know that's exactly the goal of this program really because we do have a certain section of our population that don't want to come to a psychiatrist. Um Be it the stigma be it the you know I'm not crazy whatever you may want to call it. Um So I really I have to echo what dr eyer said that you know kudos to physicians like you who develop these relationships with your patients and take so much care of them and spend so much time. I know it's not easy. Um But I do think that someone like this while I would say yeah she should have a therapist, she may never get to one. So whatever time you have with her I think is her therapy in whatever way you can help her. Um And I think yes starting her on the telegram is great. It was a good choice, Looks like it's helping her. Uh and it's a very low dose. So she if she's doing well it's great because then you have a lot of room to actually go up. You know, you can go up all the way to 20. So the next crisis comes around, you want to like bump it up, you have enough room to do it. Thank you so much. Dr Maura dr lee I see you have a hand dressed, right. Um I just want to say that, you know, a lot of times the patients are looking for empathic providers and I've had patients use me as their counselor even though they've seen therapist or a psychiatrist and they don't feel comfortable with them. And so there may be ethical cultural relational emotion. I mean there's a lot of things involved here and as long as the patient is open to the primary provider uh to receive the therapy that they need. And obviously this patient, I totally agree with the last speaker that you know, she has such a high risk with two family members committing suicide. You know, alcoholism purse as as dr cheung said maybe possibly personality disorders, you know, but with all these generous anxiety, I mean sometimes there's so many layers and multiple um you know, pectoral um that I think whenever we get the opportunity uh and we have to get the patient out of the woods first, you know? So there is no suicidality or you know, having this major anxiety attacks requiring hospitalization and possible season hypertension. I mean this is all extremely culminating and I think it's important to, you know, to me it just sounds urgent and it was great that dr chung was able to intervene. But I don't think we should always wait for them to be able to find a psychiatrist. Cause sometimes with this advent of Covid, uh most of my patients, I have a lot of Medicaid patients, they can't find a psychiatrist or a therapist. I mean it's like it's very difficult for them. And so I think it is essential that we have to play uh that intermediate role and and and hold them over treat them. And you know, when they can find the therapist, of course they can they can move on to the next level. But absolutely, I think it was quite important that he treated her great case. Thank you. Thank you so much. Dr lee other thoughts questions from folks, what do you think should be? Can I butt into a second? What do you think follow up with her should be. So initially she was kind of under duress. So we put her on medicine and I saw her back in a month. I saw back in two months and pretty soon she was doing much better and eventually like now I see her, I see her once a year for her physical. So should I be doing more than that, should I force her to come back every three months to see how she's doing or is this something that when they're stable you can just let them let them go. So I mean technically if she's totally stable on the dose that she's on and she's not asking you for extra doses of the appraisal um and she's not reaching out to you with any other crisis in between. I think, you know six months to a year is fine. Um You know we don't recommend that you need to follow them up more closely but six months is okay. I think if you can see her um just to make sure that nothing has changed. Um But other than that she's doing fine then you're good. Um Is there anything that you're worried about dr chang where you know perhaps she's not presenting and a crisis and the medication seems to be helping but you know instinct particularly given how much of a connection you seem to have established with her is important. And so I'm wondering are you asking the question because you're you're wondering if she should be seen more frequently and if that's the case, is there a worry behind that question? Well the worry is more that somebody will look at my record and say dr Cheung you've only seen her once a year, this is not appropriate if you are a psychiatrist you'd be seeing her blah blah blah blah. So you know as far as the doctor patient relationship, she's very happy. Um And you know it's been over since I started in 2015. So six years she's been on the medicine and so to make her come in every three months, she she'd freak out. She said I'm not coming to see you. If she's been on the same medicine now for six years then you've not had any issues then. No. I think there's a reason to change that. Like even us a psychiatrist actually if she was in our clinic and she had gotten to this level of stability, we would actually hand off to a primary care physician. Um We would essentially say that you can just see a PCP and we can write a note and they can continue refilling your meds because that's that's all it is. And then the fact that she has a good relationship with you, she will reach out to you if there's distress and that's all that matters. I feel I feel good about that. Good. Yeah. I think I think I'm sorry I was just gonna say that you know there isn't a need to manufacture a crisis but I appreciate your stepping back and reflecting on this because that in itself I think underscores important importance in terms of the treatment planning and and kind of reassuring the faith in that um Juliette go ahead. Yeah. No, no, no problem dr Cheung, I'm just interested and it sounds wonderful that she's doing so well. But what was the impact on you as you were treating her? Knowing her history, her family history. Um How was that before she started doing so well? Um Well, let's see. I guess I could say she was that problem patient. So, you know, there's some patients where you wonder, well, can I keep on seeing her? Because she never never gets better? Will she come back to see me? Because I'm not really doing anything. And so I would always offer her the medicine she never always rejected. I guess she got to the point where, you know, she she took it. I just looked out that I would happen to be the one that could provide it. Um I don't know if that answers your question not, but it was Yeah, no, it certainly does. And I can imagine, you know, those those are patients who make you feel very helpless, I think sort of useless and all of that. But but of course it very well could be as everyone's saying that she finally accepted it because of the relationship that you had and that you didn't tell her stop seeing me. I can't do anything for you. So now I think it's it's great that she's doing so well. Well, 11 disclaimer disclaimer is that so I knew I had to present a patient. So I had to find a patient that I've been seeing a long time, had anxiety and so, you know, family practice, you know, the chart is probably 40 visits and they're not all about anxiety and all the other, all these other things. So, you know, I have to present this to you. It's like it's a thing. So I said, well I gotta call her and talk to her. So I call her call her out and you mind, I may present you at this conference because you're a very interesting case. You did well on the medicine. So, can I hear some more about your story? And so of course I call her. She's in France, skiing, skiing and some french chalet or something. She says, I'll be glad to tell you about it. And then that's where I learned a little bit more about. I didn't really know about her mother, I knew about her brother, I didn't know about her mother, there was such a bad alcoholic and I didn't really know the full story about that when she went to bali and then she was writing a book about her life and then dredging up all the things about her life is what set her off into this whole thing. So I learned those things by calling back. So I kind of cheated to make this story better because otherwise, you know, you see pages in the office, it's just small little dribs and drabs of things, you may not get that whole story unless you sit down and talk. So I talked to her about a half hour in France. I wasn't in France, she was in France uh to get a lot of the extra tidbits of this story. That's great. Um glad she had, you know, international calls activated or something, so she's able to receive that. Um you know, I I think there's, you know, again, not to manufacture a crisis, not to create, you know, she's stable, she's stable, that's great. If a year, once a year is sufficient, that's sufficient. That's great. But to the extent that this might help folks on the call who have similar patients where they haven't reached a state of resolution yet or a state where they feel comfortable, you know, seeing the patient that, you know, spread out sort of intervals. Um I think that, you know, I just sort of wanna uh kind of point to this thing you had said about she she was the most difficult patient on your on your caseload at one point and you were sort of, you know, nothing was working. I'm curious, sort of, you know, the poll to do more the pole to try everything to be there for her, particularly if you feel like the only person that she is talking to you and I know from other contacts, dr chung that, you know, within the primary care treatment framework time is pretty compressed, You don't really have a lot of time to spend with a patient at every visit. And so if there if a patient comes along who feels like you're the only one they trust you're the only one they'll talk to. You know, they're not really connecting with therapists they've tried in the past which you're aware of, you know, medications No, she's not willing to take any medications, you're prescribing her either. Um I mean to me that's both important to talk about from a self care standpoint um and practical practicality and feasibility standpoint for you as a clinician, but there's also a diagnostic component in that um I think that sort of theirs to me, I would start to wonder, you know, in our line of work we call it counter transference, the sense of like, you know, why do I always feel like this with this patient and you know, who else in their life feels like that with them. And what is it about this presentation? What is that impact? What impact does that have on their other relationships, if people do other relationships feel similar to this person where everyone feels like they're kind of extending or overextending themselves. And so I'm curious if, you know those pieces have been a part of the picture with this patient for you or for others on the call, if you've had patients like this where you you know, you kind of feel like you're it. And so you have to go above and beyond and overextend yourself. I felt like that I feel. Um, but but usually you're not, you're not dwelling on how you, how you feel. You just take care of the problem at hand. And then like she came in many times for fatigue. I'm so tired. I got this sort through it, I got better now. I can't get out of bed. And so I look back at my notes probably, you know, four or five times from 2000 to 2015. She came with that. All the labs are normal that we don't find anything. So after you do that a couple of times and I start saying, well, you know, you know, sometimes anxiety can present with all these symptoms. Once you try try some medicine, what can it hurt? No, I'm not trying, I'm never doing it. So I guess anything. I just, since I'm old and I have many patients like that and just just little little bomb with that stealth bomb, throw it there to leave it there. I'll see you next time. And the next time he comes in, drop it off. And then finally, I think this one, I also went behind in the back door, her husband was having issues with his, you know, psyche because his wife is not easy person to deal with. So somehow he came in for his physical and I was talking about his wife and he says you know I'm gonna bring her in so we can talk together. And I think that was the thing that really help because he was there and he was saying look you need something and I was there like I told you this I told you this several times and then finally she just she caved in. I don't know if it's cave in but she agreed that maybe it would be something to try. Mhm. Yeah no I appreciate you sharing that. Yeah I'm curious if others um folks relate to that experience on the call of particularly in primary care where you feel like you're it. Um And you're overextending yourself and whether whether that offers you both information about sort of what you're doing and whether that's working or as well as sort of diagnostically what you're learning about the patient. Okay. Any other questions or thoughts um suggestions for dr cheung dr brody. Okay so I'm unneeded. Okay good. Yeah just one other thought which is that? So she's on five mg of Lexapro right? Yeah so it's a baby dose you know and and so you have to I mean you have to wonder if you know number one um is it really doing anything at that dose? And and then the second thing is uh is she taking it um because we've all we've all had patients who we discover through usually some kerfuffle involving the pharmacy or something that definitely not taking it. Um But it may not matter because the point is that you know you you offer this, she accepted it and in essence it was her decision to invest a little bit more of herself in the in the in the relationship. So it's just just a thought as I listened to the discussion that's that's a possibility. But I'm pretty sure she's taking it cause she's pretty regular and she comes in for physical every year and refill the medicine so it's been going on. Um But she didn't make a lot of other changes her Children are growing up because at the time all this was going on. Her Children were young, they're they're teenagers now so they were just toddlers at the time, she had all these problems so that adds another layer of stress and other things going on. And then somehow she got a better job at this new school that that she really loves for the time being. And so good job. Children grew up, she felt a little bit better on the medicine. All those things together may have given her the benefit. It may not be just and probably it's not just me it's all those things together. Mhm. Um I also note that she has, it sounds like sort of a therapist light on the side. Um You know in the form of a friend again I I'm left really taking in the relationship over extension in various situations with this individual. Um I sort of I'm for some reason not able to get past that um Glad she's doing better. Um And and you know one might argue having between teen kids perhaps makes you more anxious than less. Um So you know um but again glad she's doing better and I want to just note before we switch gears and moved to the didactic component um You know dr is the second case you've presented here at my matters and both times you know the feedback consistently has been that you have gone above and beyond and how much your patients trust you and um you know that you succeed in building a relationship to use dr lee's um you know description of the empathy kind of component that you bring to bear in these relationships. I just really want to note that and appreciate it and you know as much of our work all of our work sort of for behavioral health out of Mount Sinai health partners is focused in building capacity within primary care. Um And it's you know I want to just note the characteristics you bring to bear for that sort of a philosophy to come to fruition. Thank you so much for presenting this case. Thank you. Um Okay I want to switch gears to our Didactic presenter today. Dr Vanessa liftoff. Um If we could put the slides back up here we go. Um And Vanessa I hope I'm saying your last name correctly. Um Dr Lo Tov is a clinical psychologist at Mount Sinai Hospital who's going to be talking to us about screening for anxiety today and um she's she's doing a you know to like to showing special for us because she'll also be back um in february in february session to talk about psychotherapy for anxiety. So without further ado I'll turn it over to Dr Lo Tov if you have questions along the way as she's speaking please feel free to put them into the chat. Um And then that way you know you don't have to burden yourself to remember your question and then we can go through them once she's done. Thank you. Dr Lo Tov take it away. Okay. Hi everyone. Thanks for having me. Um Today I'm going to be talking about panic disorder and O. C. D. And what you might hear from clients when they're describing those symptoms. Uh Dr Cheung, now that I hear heard your case I wish I included some more information about generalized anxiety but maybe in the second round in february we can do a little bit more of that. Um Okay you can go to the next slide. So since anxiety disorders are one of the most common mental health concerns I'm going to start with a general overview right now over 40 million adults in the United States. So nearly 20% of the population have an anxiety disorder. Panic disorder specifically is experienced by 6 to 7 million adults and just under one million adolescents just to give you an idea of how many people are affected. That's almost the number of people living in new york city. The onset of panic disorder tends to happen during late adolescence and early adulthood. And when clients start experiencing symptoms it's often very sudden out of the blue with no obvious cues which can feel very alarming to them. O. C. D. Tends to occur during two. General age range is so kids may show symptoms between 8 to 12 but it also has an onset during late adolescence and early adulthood. Currently about 2 to 3 million adults and about 500,000 Children and teens have O. C. D. What's especially concerning. And also surprising is that on average it takes over 10 years for someone with O. c. d. to receive treatment and that's after they initially start experiencing symptoms. Which is a very long time. So my hope is that by talking more about these anxiety disorders specifically O. C. D. We can start closing that gap and help clients get treatment sooner. Okay, you can go to the next slide. So first I'm going to focus on the key symptoms of panic disorder. A panic attack is a sudden experience of fear dread or a sense of impending doom that occurs with at least four of the physical symptoms listed here. So a client might show up and report heart racing or fluttering dizziness, chest tightness, and sweating. Usually though there are 1-2 symptoms that feel the most uncomfortable. So, for instance, heart palpitations or their heart racing or pounding. Those are the ones that I often hear from clients with panic disorder, and those symptoms tend to tend to amplify the level of anxiety that they're feeling. Also, if someone has a panic disorder, it means they're experiencing panic attacks over and over again, which can be really uncomfortable and really disorienting for them. Next slide, clients will experience high levels of anticipatory anxiety over the physical symptoms and signs of anxiety, meaning that there's fear about having to experience that reaction from their body at all, or just dread about having another panic attack. And that's twofold first, because of how uncomfortable it feels to go through that, and also because of the belief that something is genuinely wrong in their body. Some of the anxious thoughts that you might hear from clients include, What if something's wrong with my heart? What if my heart stops, what if I stop breathing and ultimately, what if this is a sign that I'm about to die? So, at the core of this, there's a fear that the physical symptoms are a sign of an underlying medical condition. Also, even after medical conditions are ruled out these thoughts will continue to come up for clients. So we can almost expect that to be the case even after you've given them the assurance that there's nothing medically wrong. That's because those automatic thoughts have become so linked with their symptoms, which just represents the fear conditioning though that's taken place next slide in order to cope, people tend to rely on avoidance and safety behaviors to prevent or reduce the symptoms of panic that they're feeling. That can include avoidance of anything that might lead to the subtle changes in their body that trigger feelings of dread or panic. So, for instance, someone might stop exercising or drinking coffee because it increases their heart rate and that's one of their feared symptoms. Um, and one of their symptoms that have become associated with having a panic attack. Safety behaviors include an over reliance on things that reduce discomfort or alleviate fears. This includes or can include checking their blood pressure or heart rate to monitor changes, relying on other people to assure them that they're okay and that they're safe. Overall, clients are doing the best they can to cope with something that feels confusing and frightening but avoidance and safety behaviors are part of what you'll likely hear in clients descriptions of how they're coping, but also usually a cue that they need more help and more support. Next slide next I'm going to talk about how to overcome barriers in panic disorder and ways to talk to clients about what you're hearing and seeing from them. I've heard from many clients that even after several, several visits to the doctor, they didn't realize that what they were experiencing were panic attacks sometimes because those conversations weren't happening and sometimes because it took them a while to trust that that was in fact the case cultural differences can also impact how clients interpret physical signs of anxiety. So some clients may be more inclined to look for a medical explanation for what they're going through. Initially, it's really important to validate their experience so it can be helpful to let them know that while there's no medical concerns and this seems like a sign of anxiety and panic, it does not mean that what they're experiencing is just in their head and communicating to them that what they're experiencing is real and is also extremely uncomfortable. It can also be helpful to build awareness that anxiety does in fact have the power to do this and trigger that reaction from their body. Their fight and flight system is getting activated, which leads to all the physical changes, like heart racing, dizziness, shortness of breath that they experience, and even though it feels uncomfortable, it's normal and it's a natural reaction from their body. Ultimately, the message you're trying to shape is even though this feels terrifying and really uncomfortable, it's not dangerous, clients can also feel defeated, especially if they're panic attacks are getting worse or becoming more frequent. So instilling hope that there's a way to change this is important Cognitive behavior therapy for panic disorder is extremely effective and studies have shown that has a positive impact on 80% of clients, medications like SSR eyes are also useful to treat panic disorder. but studies have also shown that cognitive behavior therapy gives clients the tools and strategies to create more sustained and lasting change. Next slide, I find these screening tools helpful in assessing for anxiety disorders because they use language that's direct, but also relatable for clients. These screeners can be used as a guide to help you ask clients about their symptoms or given to clients to fill out as a self report questionnaire. Sometimes it can be hard for clients to find the language. So sometimes giving them these kind of like self report measures can be really helpful in them explaining to you what they're going through the child and adolescent screeners help assess for panic disorder as well as social anxiety, generalized anxiety, separation anxiety and school refusal. There's a child and parent version so parents can also report the symptoms are noticing in their child, which can be helpful in having a fuller picture of what's going on for adults. I've included two screening tools. The beck anxiety inventory helps assess for the physical symptoms and signs of anxiety that you'll see with panic disorder and can also co occur with generalized anxiety and social actually among the anxiety disorder kind of gamut. The penn state worry questionnaire can help you assess for generalized anxiety disorder. It focuses on whether clients are experiencing persistent worries or feel overwhelmed by them which are the key markers of generalized anxiety and usually the worry in generalized anxiety is about life events. For instance, a son or daughter leaving for college, their partner's health, a performance review that's coming up for clients with G. A. D. They feel intense uncertainty about how these things will turn out. Which can lead to significant time spent ruminating about what will happen for clients with generalized anxiety once the stressor passes the worry usually goes away until the next stressor presents itself. Next slide next I'm gonna talk about the core symptoms of O. C. D. Which includes obsessions and compulsions, obsessions are the unwanted intrusive thoughts, images or impulses that come up over and over again that feel unmanageable and beyond the person's control, obsessions are the part of the mind that says what if what if I do the wrong thing? What if something bad happens and what if I'm responsible? These what if thoughts are are also always connected to a negative outcome and can be consuming because of how real they feel. They can also lead to feelings of anxiety, guilt, shame and disgust. Or just this general feeling in their body that something feels off or feels wrong, anxiety in general is meant to be our body's alarm system. But for clients with O. C. D. That alarm symptoms that alarm system gets activated by a trigger or an intrusive thought. Usually in general when people realize they're okay that alarm system turns off. But with O. C. D. That alarm system stays on. And because it doesn't turn off, clients are driven to find a resolution to that anxiety that they're feeling compulsions. Also known as rituals are the part of the O. C. D. That's trying to turn off that alarm system. It can be any action that they take to make the intrusive thought or the feelings that they bring go away. It also includes avoidance of anything that triggers their intrusive thoughts or feelings of anxiety compulsions can be incredibly time consuming are done repeatedly and frequently and they can also extremely limit the way a person lives their lives. Um Next slide at the core of O. C. D. There's doubt and uncertainty and you'll hear that embedded into the obsessions or intrusive thoughts that clients report. When people talk about O. C. D. They tend to think about contamination or perfectionism which are types and characteristics of O. C. D. But it's also much more than that and a person can actually have an intrusive thought about anything but the ones that I've listed here and also on the next slide occur the most often and I'm going to talk about each of them in a bit more detail contamination for instance includes fears about germs or diseases or the experience of disgust when they come into contact with something they consider contaminated but there is a lesser known type of O. C. D. Called emotional contamination an emotional contamination. There's a fear that being around certain people where places will contaminate their character or change an essential part of them. Another example of emotion emotional contamination is when a person believes the intrusive, intrusive or what they consider to be a bad thought that they experience will contaminate or taint the things around them. It could be the shirt they're wearing, the room they were in or a person that they were with in this case the obsession is the intrusive or bad or what they consider to be a bad thought that they experience. But also the feelings of anxiety and disgust in response to whatever now feels contaminated. The compulsion is anything they do to get rid of the contamination like washing this shirt they were wearing or throwing it away. Next I'm gonna talk about fears of causing or experiencing harm which is a major theme across the different types of O. C. D. I'm going to focus on the last types of O. C. D. Listed in the slide because those are where this really stands out first in responsibility and checking O. C. D. There's a fear of causing a catastrophic event or accidentally hurting someone because they weren't careful enough. For example where he's about starting a fire because they didn't unplug an appliance or left their stove turned on. You'll often hear clients described rechecking items because of doubt that they didn't do a good enough or thorough enough job the last time that they checked or doubt that they even checked it. All Fear of harm is the core of harm O. C. D. Which is probably obvious given the name. But this is when someone experiences an intense fear of the unwanted violent images that are intruding in their mind. For instance pushing someone off the subway subway platform or driving off the road, they feel terrified that those images or impulses are a sign that they'll lose control and hurt themselves or someone else so they do anything they can to get rid of the thoughts, prevent or disprove them. I do want to note that in harm a city there's a fear of self harm which is entirely different from somebody from someone who is actually self harming or experiencing suicidal thoughts. Suicidal thoughts involved hopelessness and other desire not to live anymore or to escape despair. So intent is important to assess for another thing to assess is a client's current and past behavior because it can help you understand whether or not it's anxiety based but it can be difficult to distinguish. So if you're not familiar with the specific presentation, uh psychiatry consult can be useful and again for someone with harm O. C. D. There's no intent to cause harm to themselves or anyone else and they're actually so terrified of the images in their mind that they're doing everything they can to get rid of them. So that is also a good Q. And indicator to that. This is something that could be anxiety based for them. Sexual obsessions are another type of O. C. D. Where fear of harm comes up and also tends to cause a lot of shame and guilt here clients are experiencing unwanted or taboo sexual thoughts or images and that could be about family members or anyone that can be that be considered unacceptable with sexual intrusive thoughts. There's intense apprehension and fear about what these thoughts mean. And clients can start to question who they are and how they see themselves. Which can make these types of intrusive thoughts very hard for clients to talk about because of the guilt and shame tied to them. But there's nothing wrong with them for having these types of interests of thoughts. It doesn't mean anything about who they are or their character. It just happens to be what their O. C. D. Grabbed onto. And like harm O. C. D. Rituals tend to center around disproving their fears or trying to get rid of the thoughts. What you can notice across all of these obsessions is the fear that something terrible will happen to them or the people that they love and sometimes that they'll be and sometimes the fear that they'll be responsible for it. Yeah. Next slide fear of harm can also show up in just right O. C. D. But that's not always the case. Um, and just write O. C. D. There are recurrent doubts or feelings that something is incomplete not right or off. For some clients this can be tied to fears that something bad will happen unless they fix it. For instance feeling like they need to step into and out of their home the right way. Otherwise they or someone they care about will have bad luck with perfectionism. There can be fears about making the wrong choice which would lead to a long standing negative impact on their life. This can involve small choices like which subway route to take home or bigger choices like buying a home or whether or not to start medication. These decisions can lead to significant anxiety and time spent researching the best option or leave them stuck in a decision and feeling unable to make a choice at all. Sometimes clients talk about feeling paralyzed as they are trying to make a choice. Religious and moral scrupulous city. Both involved fear of violating core values that the person holds in moral scrupulous city. There's an excessive concern and also doubts about being a good or bad person or doing something wrong or immoral and religious religious obsessions. Um there's the persistent fear of doing something that goes against a person's religious beliefs. For instance committing a sin or experiencing sacrilegious thoughts or images and lastly in relationship O. C. D. Are persistent doubts about one's relationship. For instance. Fear about being in the wrong relationship. Fear of how much they love their partner or persistent doubts about trust or the genuineness of the the relationship next slide so you can have a better idea of what this looks like. I'm gonna walk through a case example. So I want you to imagine Alex a 28 year old with O. C. D. He's recently engaged and feeling excited and hopeful about the future. He's thinking about what the next 12 months will look like as they celebrate with their friends and family. But all of a sudden he experiences a sudden sense of dread and for voting, an image flashes in his mind of his partner dying. Suddenly he's overcome with fear and feels like he needs to make sure that doesn't happen to prevent it. He repeats a phrase in his mind that feels safe, then says a prayer a certain number of times. But if he doesn't say it right or it feels wrong, he needs to start again. Otherwise he can risk his partner dying and then it would be his fault after he completes the ritual, he calls his partner to make sure they're okay. But they don't answer. So the fear returns. The image of his partner dying is more gruesome this time and the rituals become even more important to get right. The obsessions for Alex are the intrusive images of his partner dying and that those feelings of dread and fear he feels when it pops up the compulsions are repeating the safe phrases and prayers and then calling to check on his partner. For people with O. C. D. Their worst fear feels possible and likely to happen. And this highlights the thought action fusion that's characteristic of O. C. D. Where people believe that just thinking about something or by just having an image pop up in their mind it means it's likely to happen to get a sense of what this feels like. I want you to take a moment and imagine something or someone that's vitally important to you or something that you'd consider to be the core of who you are. Once you have that in mind. Imagine what it would feel like if you were almost always about to lose that the lack of safety you'd feel the lack of stability and how compelled you'd feel to protect it and prevent that from happening. If you felt any discomfort as you did that imagine that amplified that's a fraction of what someone with O. C. D. Lives with every day. Um Next slide next I'm going to talk about overcoming barriers with O. C. D. And how to talk to clients about their symptoms. It's so important to validate and normalize clients experience because there can be significant shame in response to interests of thoughts if they don't know other people with O. C. D. Or haven't learned about it. They can live with intrusive thoughts alone for a very long time. Often not knowing what it is or what it means. And they can sometimes place a lot of weight on what it means about them. For instance believing there's something inherently wrong or bad about who they are. This kind of shame tends to happen often. Especially in response to harm. OCD and sexual intrusive thoughts. Having intrusive thoughts can be uncomfortable but it's normal. Again it just means they have O. C. D. It's not a sign of anything else. And actually the fears they experience are often connected to what's most important to them. Like they're partners or like their families or like their health. It can also be helpful to let clients know that the majority of people experience intrusive thoughts so they they know they're not alone in what they're going through and that it's not a representation of their character or who they are in general. It can be hard for clients to talk about because of the shame and fear they feel. So building awareness is important. This can start by acknowledging their symptoms. Primary care doctors are often also the first person clients talk to about their symptoms or at least that's what I've heard anecdotally when I've seen clients in practice. So it can be a great opportunity for creating change and reducing those feelings of shame that they're feeling also having a name for what they're going through can make a huge difference and help them make sense of what they're experiencing. It also lets them know that you've seen this before and then if you've seen this before they're not alone in it. They're not the only one that's experiencing something like this and that there's nothing unique or untreatable about what they're going through. And then as part of this conversation you can discuss with them actions that they can take in talking about treatment. A part of what you're doing is instilling hope that they can create that they can create change and won't always experience this level of anxiety or distress. Treatment is actually very effective exposure and response prevention is a type of cognitive behavioral therapy and it's considered the gold standard for O. C. D. Treatment. It's also shown to be effective for 70% of adults and up to seven up to 80% of kids and teens. Studies have also shown that clients who complete european more likely to maintain changes over time compared compared to clients who are only taking medication to treat their symptoms. Hopefully as we have more of these conversations we can catch symptoms sooner and reduce the time it takes for people to reach out get support and find treatment. Next slide. Both of the assessments listed here are self report questionnaires. However there is a version of the Yale Brown obsessive compulsive scale that's clinician administered and also um tends to be used in research studies to assess changes in symptoms. The white box provides a list of which is the Yale Brown obsessive compulsive scale provides a list of specific obsessions and compulsions that clients might experience. Also seeing the questions on here can be really normalizing for someone with O. C. D. Because if there's a whole checklist for O. C. D. Symptoms with some that they relate to again lets them know they're not the only one who's experienced this. The second question you're the obsessive beliefs questionnaire can help you understand some of the beliefs clients hold that impact their O. C. D. So it can assess for how responsible they feel to prevent bad things from happening. The difficulty experienced. The difficulty they experience in tolerating uncertainty and the need that they feel to control for or get rid of the intrusive thoughts that they experience. People also use the term O. C. D. Very loosely. So you might hear clients describe themselves as being so O. C. D. When they're just trying to describe traits of being organized, being clean or being a perfectionist. So using these assessments can be useful if clients are telling you that they have O. C. D. And you want to assess for it. Next slide. These are some resources for patients or physicians that I have personally found really helpful as I've worked with clients. The international O. C. D. Foundation provides a lot of psycho education and general information about O. C. D. On their website. They also have a directory of therapists, psychiatrists support groups and also more intensive therapy programs which can be a nice research resource because it provides that across the United States. No C. D. Is also a newer organization that provides tele therapy and accepts a range of insurance. They also have a lot of good psycho education on their website as well. And they also have discussion boards for clients which is a really nice future too. 22 again kind of like shape that sense of having a shared experience that really goes against the feelings of isolation and that sense of being alone that a lot of clients often have in the beginning. The last part includes readings that I've found very helpful the first to focus on panic disorder and the last three focus on O. C. D. These readings are helpful I think for clients they've been helpful for me and my work with clients and I think they would be useful to for anyone that's interested in just learning more about both of these anxiety disorders. What? Okay and that's it thank you so much dr lo tov I really appreciate you going into such detail. Um and especially sharing information about screeners. Um you know I want to note you know you talked about how validating it can be for patients to look at some of these self administered screeners because they see that, wow like a lot of the things that I'm experiencing, someone has heard about and to the extent that they codified it through the screener. And I think that's a really meaningful point that I want to stress. I mean a lot of what you said is really important and I'm sure folks have important and interesting questions, but I just wanted to um I wanted to note that and I appreciate you pointing that out. Um I want to start with a question from dr brody about um whether the screening tools that you shared are available in the public domains or if they're proprietary and dr brody, if you have anything you want to add to that question, please jump in. I hope they're not proprietary. I found them on online. Um, so the links provided give you public access. They are not links or like pdf that I've kind of like pulled up and attached to the slide specifically. I know for certain the child and adolescent screeners are distributed publicly on, I think it's like pen, I forgot the hospital pennsylvania University or something like that website. So that's as far as I know, but you know, for folks on the call who are curious about this, the slides from dr litas presentation as well as the recording as, as we always do, we will save it on Mind Matters website. And so you'll be able to, you know, retrieve those links later. You know, at a time when you're screening a patient you feel like part about this uh in that presentation. Let me go look it up. You know those links will remain available to you at any point in the future and you can go and check out those links and look for the screeners on your own as well. Um It'll also say the the screeners for O. C. D. Are also listed on the I. O. C. D. F. Website. So that's also where I pulled those from To the only one I'm uncertain about is the back anxiety inventory. Okay thank you. Um And you know we can certainly um do some research on that as well and um you know we send out our monthly behavioral health bulletin um We can certainly include an updated list of those that are available for folks to use. Um You know easily um dr Martinez you have a question here about effective treatments um Specifically if it's psychotherapy medication or a combination of the two. Um You know would you like to elaborate on the question any further before dr lo tov answers that um No just statistics wise like from her point of view what is most effective. I think the research studies actually show a combination of cognitive behavior therapy and medication to be most effective. There have been some studies with O. C. D. That have shown um that year P. Or your P. Plus medication is more effective than just medication as a stand alone treatment. And there's also been studies for panic disorder and O. C. D. That show clients can maintain changes for longer periods of time when they also have gotten CBT treatment because they kind of have the skills and tools to use when a trigger and a resurgence of symptoms comes up that they wouldn't necessarily have if they just stopped taking medication. Mhm. I also just you know I think anecdotally you know when I find that there's a moment in in that therapeutic work with exposure with response prevention where you can see the light bulb go off. You know where it's like once they managed to prevent the response and sit with the potential of exposure with the intrusive thought or whatever they're afraid of. You can you know it takes a while to get okay with being able to not you know engage in the response but once they do that one time I mean it almost feels palpable that there's a shift that's happened. Um And you know I've seen in my own patients their ability to then use that the next time. Unprompted is just a bit better. Right? And then from there it can progressively gain. I don't know if you you'd agree doctor I I definitely agree and I think there's learning that gets to like that clients get to experience when they're actually creating the change themselves and when they're actually also doing the exposures and practicing the response prevention. It can be really powerful and also just empowering for them to know that they can make the difference. Yeah. Um question here from dr mary day um about fear and anxiety patients face currently about going into the hospital. Um It's a really interesting and important question. Um Dr MEREDITH, do you want to elaborate on that? Perhaps not on the call when I see her? Um I don't know if you and your question was specifically about resources for primary care physicians to assess to address these conditions. Would you like to elaborate on the question? Well, yes, I was asking with regard to I'm the office manager for dr David scott. So I'm not I'm not a doctor myself. Um but I did want to ask with regard to um dr lo tov um breakdown as far as the types of fears and anxieties and just things what we're facing again from the primary care aspect when we have patients that have, you know, some significant um conditions and were were expressing their importance of them going to the er or going to the hospital because we're limited in our, you know, local facilities. They are very fearful, you know, of that and tying it into I guess just being bombarded with all of the news with regard to, you know, the pandemic. So what would be again for us, you know, some of those possible tools or you know, just those things we can utilize to address that type of scenario because we don't want patients to not go to a hospital. Um but if they have that type of fear about it, you know, we're kind of challenge as far as what we're able to do. I think that's a good question because it is a big concern for a lot of clients right now and I think that comes up with just like how connected some clients are to other areas of their lives. Obviously when it comes to medical concerns, the urgency to get that support and treatment is higher. Um but this is a case where the like the risk is there that they may or may not get covid because of an exposure. And so I think you know in part acknowledging that that's a piece of the risk and figuring out how much flexibility clients have and moving towards some of the things that are important to them, whether it's addressing a medical concern or say like reconnecting with some of the people in their lives to kind of like still create like a richness there even with some of the limitations, but it's it's a hard conversation to have because unlike a phobia which is um what you're asking clients to expose themselves to, but there's no kind of like real threat or danger. This, this is a little bit different because there is there is a risk um and I think in part having frank conversations and being open, you know and asking them about their concerns and if there is aspects of that that you can where the doctors can address to help them feel a little bit more secure in the choice to for instance, go to the hospital when they need to and maybe even figuring out like some guidelines for um scenarios that would really necessitate them going to the hospital versus scenarios that they might be able to do a telehealth appointment and that can be okay and kind of like where the benchmark lies just to kind of help them assess urgency. Yeah, well, that's kind of been pretty much our direction as far as pushing more of the telehealth since they are more comfortable um for example, with dr scott or that primary care physician that they've built a relationship with. But unfortunately a number of the patients who are particularly in our practice, you know, chronic care, um chronic kidney, so their levels are really high, so it often necessitates them actually being in the hospital, you know, from an emergency standpoint where they literally have to be taken, you know, ambulatory before we can actually get to the point where um we can really get them to a comfort level if there's, you know, if something has spiked um to the point where, you know, again, and as to your point having that family connection if it's, you know, the spouses involved, but many of them, again, you know live alone, their Children are not necessarily in the same household. So there's just a number of things. That's why I was just wondering if there was, you know, any type of, you know, resource or website or, you know, just someone who has, you know, maybe just some other additional tips that, you know, the ones that we're using now, we may just, you know, kind of run out on at some point in time. Or as they said, just to try to address some things that we can probably distribute to our patient base so that they can utilize maybe limit their access to the news. You know, probably do some other things different just internally for themselves to kind of, you know, minimize that constant bombardment that they're feeling just kind of being isolated and not able to get out um, to do some other things that would take their mind away from, um, you know, the whole the media and the pandemic. But I thank you for your response. Yeah, I appreciate the question. You know, it's it's a really relevant and important question. I imagine you're not the only folks experiencing this challenge right now, um, until dr liftoffs point, you know, this is different because, you know, some portion of that fear at least is reasonable and it's founded in reality. Um, I'm curious actually, before we go to our next question, if other folks on the call in primary care are in the same position as dr scott's practice And if you have suggestions or if you have a you know a set of talking points or a set of guidelines you've developed to help patients weigh the risk of staying home and avoiding exposure versus going to the hospital to get the treatment that you must get and what are some things they can do to to navigate to the hospital as safely as possible um When they determine that they must go. Um Do folks have strategies talking points that you've developed? You know we're also happy to try to help you message that out across the network? Okay. Um Dr cheung you have a question about you know sort of after a patient starts psychotherapy for O. C. D. Or panic um Kind of when do you know they are done? And what percentage will continue therapy do you want to elaborate on your question? We started a CBT I CBT for insomnia uh course for our providers in our offices there's so many people who can't sleep. And so we said well let's see if we can learn how to do this and see if we can do it in our practice for those people who we don't want to give medicines to. And so you know people start and I would say nobody has finished the whole course yet but when you ask them, well some of them are sleeping a little bit better. So I was wondering for O. C. D. And panic once somebody starts therapy. How many really can you say? Okay you're done? You're you're you're curing and then of those people that don't make it all the way what percentage you know make it a little way what percentage you make it halfway. Just curious because we we we got 0% to finish. I wonder what what the providers are healthcare or mental health care providers have for their percentage. Yeah it's a really good question. Um and actually one that I used to ask really often myself when I first started seeing those clients. The I think studies suggest something like say 8-12 sessions but it doesn't necessarily look like that in practice um tends to be much longer than that. And so in both treatments for panic disorder, N. O. C. D. Tend to come up with somewhat of an expert like even like a loose exposure hierarchy. So when somebody gets to kind of the end of the top of that hierarchy or that kind of like fear letter that we build together then that's kind of a point where we'll check in together to see what I'm sorry if you can hear my dog now. No worries. We love dogs. Um Sorry I don't know if if you were interrupted there dr um Yes sorry I lost my train of thought a little bit. My my um but I guess what I will say for both treatments like panic disorder and O. C. D. So there's like a there's there's a bit of a structure to the treatments and an expectation about what will be done throughout treatment usually when what we resolve one issue. There are other things that can come up. So even though it's CBT and it's it's kind of like geared to be like time limited it doesn't there's not a set number of sessions and it's really just based on how clients are experiencing their symptoms and so it's like levels of are starting to change and decreasing. So for instance with panic if panic attacks aren't happening as frequently and their level of anxiety or fear is starting to decrease when they do even experience some of those physical sensations. That's kind of a sign that we're on the on the right track. And then with O. C. D. You see something similar where they are kind of like moving towards some of the things that are important and valuable to them that maybe they were restricted by before because of the limits placed on them by their O. C. D. And you'll also see a change in um how distressing the intrusive thoughts are that they'll experience. So that's a good indicator to that there's kind of nice change that is happening. But there's not necessarily a set number or set ending in my experience at least I think it's helpful to be kind of flexible with clients as they go through the treatment and kind of like reassess and take stock and then move forward that way. That's how I found it at least. Dr Yeah, so dr Cheung. So I think, I think sort of another way to look at the question you're asking is not so much what is the treatment done, but how do you when you at what point do you switch gears when you started treatment and it's not working because we often see that, you know, patients with the best of intentions on both the patient's side of the provider side, patients go to C B. T or E R. P or whatever and I can't do, it doesn't work for them. And uh and uh you know, at some point you have to decide, you know, it's we have to have to change course. So, I mean, it's sort of an approximation. Within half a dozen of CBT treatments dot has any thoughts about this. But if someone had half a dozen treatments and not getting anywhere and it's not working or the symptoms are worsening may not may not be for them may need to take a different approach or it may be that you have to sort of backtrack reassess medication because it may be that the exposure part of exposure, response prevention therapy, it's just to anxiety making. So you need to sort of, you know, soothe the anxiety so that they can then begin to do the cognitive part of the treatment. So just another perspective. Yeah, I I think that's important to sort of, you know, underscore that like because there's a component of like collaboratively checking with the patient along the way. I think in both of what you're both saying, I think, you know, in more structured environments, that's you know, rating scales that are administered at various points in the treatment to gauge, are you actually showing reduction and symptoms are removing the needle and the direction we want to but in more um you know, sort of individual practice settings that may be more of a kind of checking in. I mean I know for me, I tend to find that at the outset of treatment often tell patients every four weeks or so, you should expect me to check with you about how this is going and what's working and what's not working. And I want you to be honest and tell me what's not working, I won't be offended by that because it'll actually help us figure out you know, what's not working so we can shift gears before we go too far. A stream down something that's not helping. Um I think framing it that way helps patients understand that you're not sort of saying guaranteed you're gonna feel extremely better in 12, 12 weeks, you're saying we're going on this journey together, this is how much time I think it'll take, this is how much time historically can take folks, but that's not set in stone. We'll check along the way. Um And you know, sometimes it's not the right treatment and sometimes it's not the right time for that treatment. So dr as dr brody said, maybe you change the sequence. You know, maybe they need to step back before they can step forward um and so on. Um We didn't talk about prolonged exposure or anything today because we weren't talking about sort of diagnostic areas where that's typically practiced, but you know, in more which is a more sort of aggressive, I would say sort of form of exposure therapy very effective. But a lot of times it can be for, you know, kind of it can be dependent on the right time in a person's life. The right combination of therapist and patient readiness for that treatment um be very effective. But there are all these factors to assess which really comes about through good therapeutic relationship, but I appreciate your attention to it. Again, I think those are the right questions to ask. Um we have about five minutes. Um any other questions from folks. Um if not, you know, I have a thought, I wanted to um raise doctor. You talked about sort of, you know, how the screener and looking at the screener and seeing all these things that one thinks is just about them listed on a form can be very validating. Um I'm curious if you can speak to the in the diadem of the therapist and the patient or you know, anybody who's having this conversation, be it a primary care provider psychiatrist or you know, um anyone the patient is talking to in a clinical capacity. Um and they're starting to tell you about these interesting thoughts they're having. You know, I find that the reaction that person has can be very impactful, right? So for example, I had a patient who would have, who had a history of pre awful childhood sexual abuse. Um and as an adult, he would experience intrusive thoughts of, you know, other Children and it would really scare him. Um and we did a lot of assessment around intent. Um and once it was kind of completely clear that this the thought of acting on those thoughts was absolutely horrifying to him and he would never do it, but the thoughts nevertheless came and they were very difficult. Um and and created a lot of self hate and so on. Um You know, I think there was probably the reason he stuck with me is that when he was telling me about it, I likely didn't convey a sense of disgust. Um and so I'm curious if you can speak to that about the value of being mindful of our reactions, not just what we're saying and asking, but what we're conveying um in these moments so that the patient can move into a place of trust. I think that is such a good um, such a good point and then such an important part of building that trust initially with clients and it's actually something that also comes up when you're actually even doing exposures with clients just in terms of like modeling for them that this is okay and that their anxiety is okay and it doesn't scare you. And so just in general, the framework I tend to take with clients when they're sharing with me about their symptoms or intrusive thoughts that, um, for them are tied to a lot of shame or guilt is just kind of like openness and curiosity because that's what you're trying to. I think for me that's what I'm often trying to shape with clients in general. So instead of having this intense fear reaction about their symptoms, were just starting to shape some curiosity for what's going on, what their thoughts are and what impacts and how it impacts them. I think a piece of that too is oftentimes with harm a city or sexual intrusive thoughts, clients are pretty reluctant to share the content of the thoughts especially in the beginning and so not pushing them too hard on that, I think is also an important piece of building that trust, but but modeling just kind of like that openness with them when they're sharing with you and just letting them know how if it feels like it fits, you know, how brave it was for them to share with you their experience or how much you appreciate them sharing their experience with you. Just kind of like pieces of that and also just like affirm the sharing in just whatever way it kind of it feels it feels authentic. Thank you so much. Um My note for about two minutes from seven so I think this is a good point to stop for the evening. Um really really appreciate everybody's time again and to get us started on on such a great note. Um Special thanks to dr cheung and dr liftoff for the case and for the didactic today, um we'll be back in february. Our next meeting is on february 9th. Again it will be from 5 30 to 7 p.m. Um really encourage everyone to come. We're hoping to build a community of collaborators through this, through this um effort. Um and you know, looking forward to seeing you all again um you know, next month in the meantime, if there are any questions about anything related to behave health um you know, for primary care, feel free to reach out to me, feel free to reach out to our team, we'll do our best to get back and try to you know, provide you any support that we can, I'm gonna tell you about some of our programs that perhaps are useful. Um I also want to encourage you to look out for our behavioral health bulletin um which lists various, you know research articles that are kind of current um kind of projects. We're working on, updates from those and so on and so forth. We try to send you as many valuable and usable links um that you can. Um It also at the very bottom of the bulletin includes a resource that Mount Sinai health system is set up for employees um for mental health called the Center for stress resilience and personal growth encourage you. You know, it's really important that we all take care of our own um mental health as well. Um you know, you can't pour from an empty cup so take the time to fill your own cup and please look out for that on the bulletin as well. And then please please please please please take a moment to complete the post survey so that we can see how we did and how valuable this session was and and continue to learn and improve mind matters. Thank you again. We'll see you in a month.